Commission on Cancer Program Standards – 2004 (Part Three of Four Part Series)

Shirley Johnson, RN, MS, MBA
Director, Oncology Services
Siteman Cancer Center

With this issue of ACE Update, Standards 5 (Clinical Trial Information) and Standard 6 (Community Outreach) will be reviewed.

Standard 5.1 Clinical Trial Information

Information about the availability of cancer-related clinical trials is provided to patients through a formal mechanism.

Discussion: The Commission on Cancer expects that a formal mechanism is established and documented to provide information about cancer-related clinical trials to patients seen at the facility. It is not acceptable to advocate fulfillment of this standard to physician offices.

Documentation Required: Prior to the on-site visit, documentation of policies and procedures for providing information about cancer-related clinical trials will be reviewed. While on-site, the surveyors will review samples of written/printed information provided to patients. Information in the SAR related to this standard is updated annually.

Standard 5.2 Clinical Trial Accrual

As appropriate to the category, the required percentage of cases is accrued to cancer-related clinical trials on an annual basis.

Discussion: The standards are very well detailed concerning the definition and requirements expected in order to meet this standard.

Documentation Required: Patient accrual is monitored and results are documented in Cancer Committee minutes. The on-site surveyor will discuss the Clinical Trials Program with the Cancer Program Team during the site visit. SAR is updated annually.

Standard 6.1 Support Services

Supportive services are provided on-site or coordinated with local agencies and facilities.

Discussion: The purpose of this standard is to ensure supportive services, prevention and early detection opportunities are provided to patients and their families either in-house or by referral. It is the expectation that the Cancer Liaison Physician be the coordinator identified for community outreach initiatives pertaining to this standard.

Documentation Required: The on-site surveyor will review flyers/brochures describing service offerings, review support group meeting schedules, and other electronic media information specific to the program. The reviewer will discuss the Community Outreach Program with the designated Cancer Liaison Physician and Cancer Committee members.

Standard 6.2 Prevention and Early Detection Programs

Each year, two prevention or early detection programs are provided on-site or coordinated with other facilities or agencies.

Discussion: Programs may be held on-site or through coordination with other facilities and/or appropriate agencies.

Documentation Required: On-site surveyor will review Cancer Committee minutes or other sources of documentation for programs offered. The surveyor will discuss this program focus with the Cancer Liaison Physician and Cancer Committee members. SAR updated annually.

Standard 6.3 Monitoring Community Outreach

The cancer committee monitors the community outreach activities on an annual basis. The findings are documented.

Discussion: The Cancer Committee is expected to annually evaluate the appropriateness of services provided to patients and the community. Methods to maintain outreach activity are set by the Cancer Committee and documented in Cancer Committee minutes. The Cancer Liaison Physician is expected to play an active role in this review.

Documentation Required: Evaluation of services is documented in Cancer Committee minutes. The on-site surveyor will review this content in minutes and discuss the evaluation process with the Cancer Liaison Physician and Cancer Committee members.

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