Work to obtain compliance in one CoC standard may not replace, duplicate, or augment the work required to obtain compliance with another standard. The sole exception to this rule is Standard 7.3: Quality Improvement Initiative.
Please note: Restrictions against using the same report for Standard 2.2: Cancer Liaison Physician and Standard 6.4: Rapid Cancer Reporting System will not be enforced until 2025.
The following are some examples of noncompliance:
- Program initiates a prehabilitation program for patients preparing to undergo oncologic surgery. It reviews and reports this for Standard 4.6: Rehabilitation Care Services but, because the program designates survivorship as beginning at the time of diagnosis, also considers and reports this under Standard 4.8 as one of three survivorship services.
- Program focuses on screening for recurrent/new primary malignancies for breast cancer survivors, estimates number of patients receiving that service in a calendar year, and reports this as one of its three survivorship services for Standard 4.8. It has a 1-day event offering breast cancer education and screening to survivors and reports this as their Standard 8.3 screening event.
- Program currently refers patients to off-site location for all genetic testing. The program makes a goal for Standard 7.4: Cancer Program Goal to hire a genetics professional so that services can be offered on-site. This is considered meeting the requirements of Standard 4.4: Genetic Counseling and Risk Assessment that genetic services be offered on-site or by referral.
- The Cancer Liaison Physician presents a report of quality measures from the Rapid Cancer Reporting System (RCRS) with the intent of satisfying the requirements for both Standard 2.2: Cancer Liaison Physician and Standard 6.4: RCRS: Data Submission. Standard 2.2 CLP reports cannot duplicate the RCRS report for Standard 6.4.
The following are some examples of compliance:
- Program initiates a prehabilitation program for patients preparing to undergo oncologic surgery. It reviews and reports this for Standard 4.6: Rehabilitation Care Services. Program separately analyzes physical therapy services for patients who have completed their first course of treatment and reports this under Standard 4.8 as one of three survivorship services.
- Program focuses on screening for recurrent/new primary malignancies for breast cancer survivors, estimates the number of patients receiving that service in a calendar year, and reports this as one of its three survivorship services. It has a one-day event offering breast cancer education and screening to unaffected family members of breast cancer patients and reports this as its Standard 8.3 screening event.
- Program discovers it is not providing adequate referrals for psychosocial issues. After reviewing referral data at the cancer committee for Standard 5.2: Psychosocial Distress Screening, it is decided that the upcoming QI project will be focused on improving referral numbers.
Questions on the above guidance should be submitted to the CAnswer Forum.
