Value of CoC Accreditation

1. Value of CoC Accreditation

2. The American College of SurgeonsandThe American Cancer SocietyPartners to Improve the Lives of Cancer Patients The American Cancer Society funds the American College of Surgeons development of an approval program for cancer care clinic 1926 The American Cancer Society funds the Cancer Physician Liaison programs to engage physicians in Commission on cancer accredited programs 1963 The American College of Surgeons and the American Cancer Society start their second century of their partnership 2013 1988 The American College of Surgeons pilots the National Cancer Data Base, the largest repository of cancer patient date in the world 1959 The American Cancer Society and the America College of Surgeons are the founding members of the American Joint Committee on Cancer to formulate and publish cancer classification systems and staging 1913 Overlapping groups of physicians found both the American College ofsSurgeons and the American Cancer Society The Commission on Cancer gratefully acknowledges the support of the American Cancer Society for their support of the National Cancer Data Base

3. Commission on Cancer Multi-disciplinary program Quality Care 50 national professional organizations

4. Quality Improvement through Accreditation CoC set Standards Provide Rigorous Data

5. Benefits of CoC Accreditation Demonstrates commitment to quality care. Improved patient outcomes across all domains of cancer care. Dedicated resources to provide the screening, prevention treatment and support services. Use of data applications to serve as the basis for quality improvement. THINK ABOUT HOW THESE BENEFITS HELP YOUR CANCER PROGRAM AND PATIENTS!

6. Value of CoC Accreditation PAYERS CEOS PROVIDERS POLICYMAKERS PATIENTS Affect cost; increase revenue; ensure compliance Show improved outcomes; lower costs Give tools, information and structure to deliver best care Proof of concept; educate public; demonstrate value Reassurance and information about quality of care Reputation, Compliance Compliance Credentialing Tools/ Structure System/ Education Public Education

7. Commission on Cancer’s Response: ‘Cancer Program Standards: Ensuring Patient-Centered Care’ Focus on quality of care via performance metrics and quality improvement. - Accountability & QI measures - Genetic assessment and counseling - Palliative care services - Increase clinical trial accruals - Prevention and early screening - Studies of quality and improvements - Public reporting of outcomes - Patient navigation (2015) - Psychosocial distress screening (2015) - Survivorship care plan (2015)

8. CoC-Accredited Cancer Programs 37 7 11 7 6 16 23 10 7 71 37 5 38 1 40 12 72 15 5 12 25 81 48 5 75 47 103 13 23 39 11 7 34 26 35 39 37 8 15 8 5 17 4 19 11 42 85 32 72 3 2 Around 1500 CoC-accredited cancer programs in the US and Puerto Rico 6

9. The National Cancer Data Base (NCDB) is a nationwide oncology database that verifies data submitted by the registries of all CoC-accredited cancer programs. • NCDB Tools: • Cancer Program Practice Profile Reports (CP3R) • Rapid Quality Reporting System (RQRS) • Quality Measures • Cancer Quality Improvement Program (CQIP) • Participant User File • NCDB Data Completeness Reports • Hospital Comparison Benchmark Reports • Survival Reports

10. Cancer Program Practice Profile Reports (CP3R) Provides feedback to: Improve the quality of data across several disease sites. Foster pre-emptive awareness to the importance of charting and coding accuracy. Improve clinical management and coordination of patient care in the multidisciplinary setting. Updated CP3R Report includes several modifications: For 2014 surveys, cases diagnosed in 2010 and 2011 are reviewed (Standards 4.4 and 4.5). CP3R update involves data submitted during 2012 and 2013 NCDB “Calls for Data”.

11. Utilizing CP3R Data

12. Why Use RQRS? This is old news!

13. Rapid Quality Reporting System (RQRS) Allows expedited data entry of a critical items specifically relevant to anticipated standard of care treatments. Enables data reporting on patients concurrently. Shows up-to-date concordance rates relative to other programs. Provides hospitals timely notification of treatment expectations allowing intervention (e.g. transportation) when patients have not received all components of treatment. Generates Treatment Summaries.

14. RQRS Participation 22 5 4 3 4 9 12 1 2 21 14 2 27 1 11 2 29 9 10 2 14 32 0 23 24 24 41 7 14 13 2 2 2 9 17 21 8 1 1 6 4 8 1 4 5 31 26 11 19 1 0 1 765 participating sites ~ 54% of CoC Accredited Institutions

15. RQRS Benefits Identify patients who are at risk of “slipping through the cracks”. Encourages collection of adjuvant treatment information and assists with the prevention of delay patients’ treatment. Compares your performance rates with other participating cancer programs; and performance over time.

16. Using the RQRS Features Year-to-date performance dashboards Online prospective alerts Emailed monthly alert reports Patient Rx summary report Comparison reports

17. Quality Measure Reports COLON Adjuvant chemotherapy for lymph node positive At least 12 lymph nodes are removed and examined RECTUM Radiation therapy with surgical resection (quality improvement measure) BREAST Post breast conservation irradiation Combination chemotherapy for hormone receptor negative Adjuvant hormonal therapy for hormone receptor positive Breast conserving surgery rate (surveillance measure)

18. Cancer Quality Improvement Program (CQIP) • CQIP = Data-drivenprocess and outcomes-basedcancer quality improvement initiative. • Website accompanies the slide set providing information supporting reports, technical details, report creation, and scientific justification and references for quality measures. • Initial release data includes: • Compliance with CoC-adopted quality measures • Volume data for complex surgical oncology operations with 30-day mortality (if a minimum volume threshold is met) • Unadjusted survival data for selected cancer sites • Other clinical data and administrative data, which will be updated and expanded annually.

19. Participant User Files Investigators can apply for a disease site-specific Participant User File (PUF). Used to review and advance the quality of cancer care through analysis of cases reported to the NCDB. Promotes retention of physicians at your facility. International and national presentations, and peer-reviewed publications. 178 applicants in 2013.

20. NCDB Data Completeness Report Purpose: Informs programs about incomplete data in abstracts. • Report and Case Identifiers • Patient Characteristics • Diagnostic and Staging Items • Surgery Items • Radiation and other treatment Items • 2011 data submitted in 2013; 2012 in 2014  • 5-year follow-up for cases diagnosed in 2006; 2012 data submitted in 2014 Content of Completeness Reports

21. Hospital Comparison Benchmark Reports Aggregates and compares: • Hospital system • State • Region • National Assist with product line analyses and program assessments: • Define where your hospital is losingor gaining patients • Identifies areas for outreach • Data for grant applications

22. Survival Reports Unadjusted Survival Rates by Stage Breast Cancer Colon Cancer Non–Small-Cell Lung Cancer Prostate Cancer

23. INSPIRING QUALITY “Driven by Highest Standards, Better Outcomes” [Video Link] http://inspiringquality.facs.org/gallery/videos/