Meeting CoC Standards: Chapter 5 Data Quality

2. Meeting CoC Standards Chapter 5 Data Quality Sheryl Daugherty. RHIT, CTR Senior Client Relationship Manager Sharon Metzger, CTR Director of Consulting Services

3. Welcome • Thank you for joining us today for our webinar • We will take questions and comments at the end of the presentation • You may enter your questions into the “Question” box on the GoToWebinar screen • The webinar is being recorded and the recording, slide deck and Q&A will be made available at our website: Oncolog.com

4. FYI • Meeting CoC Standards: Chapter 5 Data Quality has been award 1 CEU by NCRA • You must be registered and logged in to receive a Certificate of Attendance which will be emailed to you within 3 weeks • The webinar is being recorded and the recording, slide deck and Q&A will be made available at our website: Oncolog.com “VIEW OUR WEBINARS” within 2 weeks

5. Goals for Today • Review the requirements to meet the standards in Chapter 5 Data Quality • Identify requirements for documentation and compliance • Share examples, offer suggestions and provide clarification

6. Required Documentation • CoC accredited cancer programs document cancer program activity using multiple sources, including policies, procedures, manuals, tables and grids; however, cancer committee minutes are the “primary source” for all documentation of cancer program activities*. • All meeting minutes should contain sufficient detail to accurately reflect the activities of the cancer committee, as well as demonstrate compliance with the CoC standards.* • *Cancer Program Standards: Ensuring Patient-Centered Care page 11

7. Chapter 5: Data Quality • Standard 5.1 Cancer Registrar Credentials • Standard 5.2 Rapid Quality Reporting System (RQRS) Participation • Standard 5.3 Follow-Up of All Patients • Standard 5.4 Follow-Up of Recent Patients • Standard 5.5 Data Submission • Standard 5.6 Accuracy of Data • Standard 5.7 Commission on Cancer Special Studies

8. Standard 5.1 Cancer Registrar Credentials Case abstracting is performed by a Certified Tumor Registrar

9. Definition and Requirements • All cancer registry staff who abstract cases at a CoC-accredited program must either: • Hold a current Certified Tumor Registrar (CTR) credential or; • Perform case abstracting at a CoC-accredited program under the supervision of a CTR • A plan for CTR supervision of non-credentialed staff must include the scope, quality control, education and training activities • Any non-CTR hired to perform abstracting under the supervision of a CTR in a CoC-accredited program must pass the CTR exam within 3 years of the date hired. • If the CTR credential is not successfully obtained within the three-year grace period, then he or she may not perform case abstracting at any CoC- accredited program until the credential is obtained.

10. Eligibility Routes for CTR

11. Plan for Supervision of non-CTR staff Standard 5.1 Plan to Supervise Non-CTR Abstracting All cancer registry staff who perform abstracting at a CoC-accredited program must either: 1. Hold a current Certified Tumor Registrar (CTR) credential, or 2. Perform case abstracting at a CoC-accredited program under the supervision of a CTR Policy: All newly hired abstractors are required to pass the CTR Certification Examination within 3 years of date of hire. Current staff who move into an abstracting position must also pass the CTR Certification Examination within 3 years of transfer into the position. If certification is not achieved within 3 years or the exam is failed, the abstractor may longer abstract CoC required cases Training Plan: The Quality Control Coordinator, based on the educational background and experience level of the staff member, will provide education and training from the following SEER resources: Hematopoietic & Lymphoid Neoplasms Online Training Multiple Primary and Histology Coding Rules Training SEER's Training Web Site SEER Self Instructional Manuals for Tumor Registrars SEER Advanced Topics for Registry Professionals Plan to Supervise Non-Certified Abstractors: The Quality Control Coordinator is responsible for supervising abstracting done by non-credentialed staff, monitoring data quality and providing training and education based on findings of the quality control. For the first three months, 100% quality control will be performed on all data elements in analytic abstracts. When an error rate of 10% or less is achieved, monitoring will decrease to 25%. When an error rate of 5% or less is achieved, case review will decrease to 10% and continue at 10% until certification is obtained or the error rate increases. In which case, quality control will move back to 25%. All errors will be reviewed with the abstractor on a bi-weekly basis and training and education will be provided as necessary. Errors and error rates will be documented and monitored by both the Quality Control Coordinator and the Registry Manager (See attached spreadsheet)

12. Rating Compliance Each calendar year, the program fulfills one or both of the following compliance criteria: • Case abstracting is performed by a Certified Tumor Registrar. • Non-credentialed staff that abstract cases and who are in the three-year grace period are supervised by a Certified Tumor Registrar.

13. SAR Documentation • Summary of Cancer Registry Staff • Registry Staff Education and Credentials • Upload the plan for supervising non-CTR staff performing abstracting

14. Clarification • Applies for CoC required cases (analytic) • Includes all staff including contractors • Registrars start date, end date, credentials and position must be entered into SAR if the worked for your registry for 3 months or more • CTR is responsible for submitting data to RQRS and uploading data to the NCDB during the annual call for data. • Non-CTRS can perform abstracting under the supervision of a CTR and the non-CTR must pass the CTR examination within a three year period • First recurrence information must be entered by a CTR

15. Clarification • % of quality control required for non CTRs abstracting cases • The CoC does not have set minimums percentages for CTR review of non-CTR credentialed work. The level of QC review should be based on the knowledge and experience of the non-credentialed staff as well as the quality of the work performed. 10% review is probably the minimum standard. • A person who fails pass the CTR exam after the 3 year period may not abstract until they pass the exam but can perform other duties in the registry • Non CTRs can abstract cases not required by CoC (depending on your state rules),they perform case finding and follow-up (but may not add first recurrence information or first course treatment information since it is part of the CoC required abstract • If a CTRs certification lapses they must have their CTR reinstated first before abstracting. They can perform other non-abstracting activities in the registry in the mean-time

16. Rating Compliance Each calendar year, the program fulfills one or both of the following compliance criteria: • Case abstracting is performed by a Certified Tumor Registrar. • Non-credentialed staff that abstract cases and who are in the three-year grace period are supervised by a Certified Tumor Registrar.

17. Standard 5.2 Rapid Quality Reporting System (RQRS) Participation From initial enrollment and throughout the accreditation period, the cancer program actively participates in RQRS, submits all eligible cases for all valid performance measures, and adheres to the RQRS terms and conditions.

18. Definition and Requirements • Programs must actively participate in RQRS submissions and adhere to the RQRS requirements from initial enrollment (or from the beginning of the accreditation period) up until survey. • RQRS data and performance must be reported to the cancer committee semi-annually. • The Cancer Liaison Physician may report RQRS data and performance in partial fulfillment of the requirements for Standard 4.3. • All programs that are undergoing initial survey for accreditation and pediatric programs are exempt from this standard. All other programs must fulfill the requirements of this standard.

19. RQRS Participation The full details for RQRS participation are provided in the RQRS terms and conditions available on the National Cancer Data Base (NCDB) website: facs.org/ quality-programs/cancer/ncdb/qualitytools/rqrs

20. RQRS Overview - Dashboards • The rating dials for each measure monitored and reported  through RQRS, show the current facility performance  rate. • The rates indicate the proportion of patients for whom adjuvant therapy was expected to be started within the last 365 days.

21. RQRS Overview - Alerts • The alert screen identifies cases where pending information on the administration of adjuvant therapy has not been reported to the RQRS. • Non-concordant cases remain on the Alert screen for 120 days, allowing time for review.

22. Clarification • Programs undergoing initial survey and pediatric programs are exempt from this standard. • Cases do not need to be completed to submit them to RQRS. The are resubmitted when updates are made to the case. • Cases that are rejected are to be corrected and resubmitted each month. • RQRS data and performance must be reported to the cancer committee and documented in the minutes semiannually for compliance and quarterly for commendation. • RQRS data reporting can be done by any appropriate cancer committee member. This includes the CLP and the CTR.

23. Minimum RQRS Data Submission Requirements • FIN • Accession/sequence number • Sex • Patient zip coed at diagnosis • Date of diagnosis • Primary Site, Histology, and Behavior • NAACCR Record version • Record Type • Last Contact Date

24. SAR Documentation • The SAR documentation for this standard is auto-populated by NCDB. • This will include a listing of every RQRS data submission that was made during the accreditation cycle. • Documentation includes the date and time of submission, the file name and the status of that submission.

25. Rating Compliance • For Compliance: Each calendar year, the program: • Submits all new and updated cancer cases at least once each calendar quarter. • RQRS data and performance reports are reviewed by cancer committee at least semi-annually and documented in the cancer committee minutes. • For Commendation: Each calendar year, the program: • Submits all new and updated cancer cases at least once each calendar month. • RQRS cancer cases are submitted within three months of date of first contact. • All cancer cases submitted to RQRS with edit errors are corrected and resubmitted. • RQRS data and performance reports are reviewed by cancer committee at least quarterly and documented in the cancer committee minutes.

26. Standards 5.3 Follow-Up of All Patients and 5.4 Follow-Up on Recent Patients Standard 5.3: For all eligible analytic cases, an 80 percent follow-up rate is maintained from the cancer registry reference date. Standard 5.4: A 90 percent follow-up rate is maintained for all eligible analytic cases diagnosed within the last five years or from the cancer registry reference date, whichever is shorter.

27. Definition and Requirements • Long-term follow-up is essential to evaluate outcomes of cancer care. • Accurate follow-up data enable the program to compare outcomes with regional, state, or national statistics. • Follow-up information is obtained at least annually for all living analytic cases included in the cancer registry database. • The cancer committee monitors the use of (unknown) values to ensure complete data reporting. This monitoring is extremely important for information describing the date of first recurrence, type of first recurrence, and cancer status. • It is expected that all CoC-accredited programs will provide follow-up information and assistance to other facilities involved in the patients treatment or follow-up care.

28. Cases Not Requiring Follow-Up • Residents of foreign countries • Cases that are reportable by agreement • Patients whose age exceeds 100 years and who are without contact for more than 12 months • Patients diagnosed on or after January 1, 2006, and classified as Class of Case 00

29. Sources for Follow-Up Information Include but are not limited to: • Following or managing physician(s) • Other Services at Your Facility • Pathology reports or death certificate • Patient or patient’s family • Internet sources (such as death index, patient locator software, obituary listings) • Other Facility’s Cancer Registry

30. Exceptions by Category & Specifications • All programs fulfill both standards as written except programs in all categories undergoing initial survey and PCP facilities. • Programs undergoing initial survey and PCP facilities are exempt from these standards. • Std. 5.3 - In a Pediatric Cancer Program (PCP) facility, for all eligible analytic cases, a 60 percent follow-up rate is maintained from the cancer registry reference date. • Std. 5.4 - In a PCP, annual follow-up information is obtained for eligible analytic cases until the patients reach the age of 26 years. Once patients reach the age of 26 years, follow-up attempts are to continue, but the data for the patients are excluded from the follow-up calculations

31. Rating Compliance Standard 5.3: • Excluding patients with age-specific exclusions, an 80 percent follow-up rate is maintained for all eligible analytic cases from the cancer registry reference date • For PCP facilities, a 60 percent follow-up rate is maintained for all eligible analytic cases from the cancer registry reference date. Standard 5.4: • Excluding patients with age-specific exclusions, a 90 percent follow-up rate is maintained for all analytic cases diagnosed within the last five years or from the cancer registry reference date, whichever is shorter.

32. SAR Documentation Std. 5.3 & 5.4 .

33. Standard 5.3 and 5.4 Clarifications • Neither Standard 5.3 nor 5.4 require reporting to the cancer committee on follow-up statistics, but this information should be included in the Registry Report. • When completing the SAR, only the current follow-up numbers will be entered. There are not separate fields for each year in the survey cycle. • Follow-up activities may be completed by non-CTR staff members. • A cancer registry policy on follow-up procedures must be included in the Policy and Procedure Manual.

34. Standards 5.5 Data Submission Each year, complete data for all requested analytic cases are submitted to the National Cancer Data Base (NCDB) in accordance with the annual Call for Data.

35. 2018 Data Submission Requirements

36. Definition and Requirements • Data submission to the NCDB must be performed by using the CoC’s secure online data submission application in accordance with the annual Call for Data specifications. • After the initial survey of a new program is completed and accreditation is awarded, the program submits data to the NCDB for all applicable years currently accepted by the NCDB • New programs will submit all analytic cases for any diagnosis years beginning with your Reference Date. • Programs in all categories undergoing initial survey for accreditation are exempt from this standard. A new program’s initial data submission to the NCDB will occur during the first Call for Data after the new program is accredited. All other programs must fulfill the standard as written.

37. Standard 5.6 Accuracy of Data Annually, cases submitted to the National Cancer Data Base (NCDB) that were diagnosed on January 1, 2003 , or later meet the established quality criteria and resubmission deadline specified in the annual Call for Data.

38. Definition and Requirements • Standardized data edits are applied to all analytic cases submitted to the NCDB. • The reporting registry is notified of problematic cases through an edit report. • The reporting registry must correct outstanding data quality errors resulting in rejected records. • Rejected cases are those that do not meet specified data quality criteria. • Problematic cases diagnosed on January 1, 2003, or later are corrected and resubmitted by the deadline specified in the Call for Data. • All submitted cases must satisfy the established quality criteria by the deadline date specified in each Call for Data.

39. Clarifications Standards 5.5 and 5.6 • Programs in all categories undergoing initial survey for accreditation are exempt from standards 5.5 and 5.6. • A new program’s initial data submission to the NCDB will occur during the first Call for Data after the new program is accredited. • All other programs must fulfill this standard as written. • No official report to the cancer committee is required for Standards 5.5 and 5.6, but noting that the submission was made on time and that there were no errors should be a part of the registry report.

40. SAR Documentation Standards 5.5 and 5.6

41. Rating Compliance Standards 5.5 and 5.6 Standard 5.5 • For each calendar year, complete data for all requested analytic cases are submitted to the NCDB in accordance with the annual Call for Data. Standard 5.6 • Identified errors in submitted cases and rejected records are corrected by the due date specified in the Call for Data. • Corrected cases are resubmitted to the NCDB by the due date specified in the Call for Data. • For Commendation: The cases diagnosed on January 1, 2003, or later meet the quality criteria for the annual Call for Data on initial submission.

42. Standard 5.7 Commission on Cancer Special Studies The cancer program participates in special studies as selected by the Commission on Cancer.

43. Definition and Requirements • The CoC will periodically design and conduct special studies. Based on study criteria, selected accredited programs will be required to participate for compliance with this standard. • The cases to be included in the study, what data to include, and due date will be specified in the study documentation provided by the CoC. • To fulfill the standard, all selected programs must submit all requested information for the cases identified by the specified deadline.

44. Clarifications • Programs in all categories undergoing initial survey for accreditation are exempt from this standard. • All other programs must fulfill this standard as written. • SAR/PAR will auto populate with number of cases required and submitted for each study.

45. SAR Documentation .

46. Rating Compliance • Participation in each Special Study, as mandated by the CoC.

47. Required Documentation for Chapter 5: Data Quality

48. Resources used for this webinar: • CAnswer Forum http://cancerbulletin.facs.org/forums/ • Standards Resource Library http://cancerbulletin.facs.org/forums/CAnswerForumHome/StandardResourceLibrary • Cancer Program Standards: Ensuring Patient-Center Guidelines 2016 • CoC/NCDB/RQRS: www.facs.org/ quality-programs/cancer/ncdb/qualitytools/rqrs

49. QUESTIONS

50. FYI • This webinar has been award 1 CEU by NCRA • You must be registered and logged in to receive a Certificate of Attendance which will be emailed to you within 3 weeks • This webinar is being recorded and the recording, slide deck and Q&A will be made available at our website: Oncolog.com “VIEW OUR WEBINARS” within 2 weeks