CLARIFICATION NOTES FROM CHAPTER 2: CLINICAL SERVICES WEBINAR
10/25/17
Clarification for Standard 2.1 CAP Protocols
- Role of the cancer registrar in the quality control review of pathology reports
The cancer registrar may identify cases for the review and tabulate the findings, but has no other role in the process
Clarification for Standard 2.2 Oncology Nursing
- Do nurses need an oncology certification to administer chemo?
NO However, each calendar year they must attend training in chemotherapy administration, and that training must be documented with proof
- Must all educational programs be provided by ONS or ONCC?
No, the CoC doesn’t not require that education be provided via ONS or ONCC but they do encourage programs to use educational models from recognized nursing organizations
- Are all RNs included in the denominator?
This is a quote from the CAnswer Forum regarding is question. It was posted on 12/28/16 by a Senior Member of the Accreditation and Standards Staff:
“The denominator includes any nurse providing direct, clinical oncology care to cancer patients. Effective January 1, 2016 commendation will be awarded when 25% of the oncology nurses employed and/or contracted with the facility (including full-time and part-time) hold a current, applicable oncology nursing certification. This means that the denominator in the commendation calculation no longer depends on whether the oncology nurse is chemotherapy-trained. Instead, the denominator includes any nurse providing direct oncology care to cancer patients”
- Are LPNS included in the denominator?
NO, LPNs are eligible for OCN certification
- Are per-diem staff included in the Part-time category?
YES, per diem staff are included in the part time category if they worked for three consecutive months.
Clarification for Standard 2.3 Genetics Counseling
- Requirement for a genetics professional on the cancer committee
A genetics professional is a required member of the cancer committee, IF THE SERVICES ARE PROVIDED ON SITE.
- Referral policy
The CoC does specify what is required in the referral policy. That can be determined at the local level. However, the cancer committee is minimally required to review the actual referral process to make sure it is working properly and the service is being provided to all appropriate patients. The committee should also make recommendations for improvements as necessary.
- Tracking the number of referrals
Is not required to be included in the report to the Cancer Committee. But tracking referral information along with other data points can assist in strategic planning for the service.
- Sources for required documentation
The genetics professional should provide all of the required documentation for this service and report to the cancer committee annually
Clarification for Standard 2.4 Palliative Care Services
- Policy and Procedures
The CoC does not provide a list of minimum requirements for this standard. But these suggestions were provided on the CAnswer Forum:
Define goals for the service
Define which patients are eligible to be assessed and/or referred for services
Define the services that will be provided and if they will be on-site or by referral
If services are referred, identify the facility, practice, or agency
- Review and monitoring in the minutes
The cancer committee minutes must reflect the review and monitoring of the process for providing palliative care. Some suggestions: the number of patients being referred to the services (are they as expected?); Are there any issues with patient access to the service;
The issues raised and any ensuing recommendations or actions must be documented in the cancer committee minutes. A simple acceptance of the report as written, does not meet the standard