Penn Cancer Network
Cancer Registrars’ Meeting
Examples of Report Templates
12/14/21
Cindy Stern, RN, MSN, CCRP
Senior Administrator
Penn Cancer Network
Objectives
Describe approaches for completing CoC report templates that demonstrate
compliance with select standards for Cancer Program Accreditation
Identify examples of non-CoC supplied report templates that provide
documentation of compliance with Cancer Program Accreditation standards.
Report and Evaluation Templates
2.1
CoC Supplied Templates
Cancer
Minutes
NonCommittee
CoC Templates
2.5 Genetic
Multidisciplinary
Case
Conference
4.4
Counseling and
Risk
Assessment
4.1 Palliative
Physician
4.5
CareCredentials
4.2 Rehabilitation
Oncology Nursing
4.6
ServicesCredentials
4.3 Nutrition
CancerServices
Registry Staff Credentials
4.7
5.1 Survivorship
PathologyProgram
Report Review
4.8
6.1 Psychosocial
Cancer Registry
Control
5.2
DistressQuality
Screening
7.2 Addressing
Concordance
with
Guidelines
8.1
Barriers
to EB
Care
7.3
Quality Improvement Initiative
7.4
Cancer Program Goal
8.2, 8.3
Community Outreach
9.1
Clinical Research Template
All
CoC Standards Template Change Log
Info to Add to All Non-CoC Templates
XYZ Hospital Cancer Program
Standard Number/Title Report (year)
Top Portion of Report
Report provided by: ________________________________
Date report discussed at Cancer Committee: ____________________
Insert report contents
Evaluation; Analysis of Outcomes:
Bottom Portion of
Report- After Data is
Documented:
Recommendations; Quality Improvement if Warranted:
Std 4.4 Evaluation of Genetic Counseling and Risk Assessment
Genetic services are provided: □ Onsite
□ By Referral
Disease Site Focus Report: fill in name of disease site
Data is from: fill in year
Date Reported to Cancer Committee: fill in date
Report submitted by: fill in name
Outcome Measures
Total number of pts with fill in name of disease site
OUTCOMES
Number
Number of fill in name of disease site pts who met NCCN guideline criteria for genetics referral
(Denominator)
Of the number of pts with fill in name of disease site above who met NCCN guidelines for genetics referral,
the number who received a genetics referral (Numerator)
Analysis of outcomes for disease site focus:
Recommendations and Quality Improvement (if warranted):
%
Std 4.4 Evaluation of Genetic Counseling and Risk Assessment
OUTCOME MEASURES
Estimated analytic volume (year______)
Total number genetic referrals
Number of pts declining referral +/or testing
Number of unknown outcomes
Number of pts who have completed counseling but
not testing
Number of pts who have completed both
counseling + testing
Number of pending test results
NUMBER
%
•
% of total number of referrals = number of referrals divided
by analytic volume
•
All other % values relate to the total number of referrals as
the denominator; for example:
 % of pts declining referral +/or testing =
 Number of pts declining referral +/or testing (25)
divided by total number of referrals (100) = 25%
+ Mutation
Number
%
Referrals by cancer site:
 Breast
 Prostate
 CRC
 Ovarian
 Pancreatic
 Other (describe:
)
Other Referrals in individuals without cancer
 Family history of cancer
 Known mutation in family member
 Other (describe:
)
TOTALS
VUS
Number
%
No Mutation
Number
%
Std 4.4 Evaluation of Genetic Counseling and Risk Assessment
Useful for quality study and need for improvements
Referral Sources
Total number of referrals
Self-referred
PCP
Imaging
GI
GI surgery
Urology
Gyn
Gyn Onc
Breast Surgery
Medical Oncology
Radiation Oncology
Other (identify:
)
Other (identify:_________)
Number
%
Physician
Number Referrals
%
Dr A
Dr B
Dr C
Dr D
Dr E
Key separate key with MD names
Analysis of Genetic Services:
• Strengths, gaps, barriers
Recommendations and Quality Improvement (if
warranted):
Std 4.5 Evaluation of Palliative Care Services

Include at top of template:
• Data year, date of report to Cancer Committee, person providing report

…the program must evaluate the number [approximate] of … patients referred for palliative
care services and for what services or resources, regardless of whether the referral is to an
on-site or off-site location.”
•

“The standard applies to patients receiving care with curative intent, as well as palliative intent.”
(Source: Standards and CAnswer Forum)
Consider including the following info on the template or at least in the minutes:
•
Criteria used to trigger referrals
Std 4.5 Evaluation of Palliative Care Services by Resources
Palliative Care Services Are Provided: □ Onsite
□ By Referral
Total Number of Palliative Care Referrals =
Type of Palliative Care Referrals
Pain management
Non-pain symptom management
Psychosocial support
Advanced care planning – Goals of care
Transitions of care – continuity of care
Hospice coordination, end of life care, bereavement
Spiritual needs
Physical needs (rehab, PT, OT, speech, etc)
Practical needs (financial, insurance, vocational, etc)
Integrative Therapy
Analysis/evaluation of palliative care services:
•
Criteria to trigger palliative care referral:
•
Strengths, gaps, barriers:
Recommendations + Quality Improvement (if warranted):
# of pts referred
% of referrals
Std 4.5 Evaluation of Palliative Care Services By Site
Palliative Care Services are provided: □ Onsite □ By Referral
Total Number of Palliative Care Referrals Across All Cancer Sites
Breast
Lung
PALLIATIVE SERVICES
#
%
#
%
Pain management
Non-pain symptom management
Psychosocial + coping support
Advanced care planning-goals of care
Transitions of care (ie: continuity)
Hospice coordination, bereavement
Spiritual needs
Physical needs (rehab, PT, OT, speech, etc)
Practical needs (financial, insurance, etc)
Integrative Therapy
Other (Describe:
)
Total Number of Palliative Care Referrals
Analysis/evaluation of palliative care services:
• Criteria to trigger palliative care referral:
• Strengths, gaps, barriers:
Recommendations + Quality Improvement (if warranted):
Colorectal
#
%
Prostate
#
%
Myeloma
#
%
Lymphoma
#
%
All Sites
#
%
PALLIATIVE SERVICES
Pain management
Non-pain symptom
management
Psychosocial and coping
support
Advanced care planning
Transitions of care –
Continuity of Care
Hospice, end of life care,
bereavement
Spiritual needs
Physical needs (rehab, PT,
OT, speech, etc)
Practical needs (financial,
insurance, vocational,
etc)
Integrative Therapy:
symptom management
Total Number of Palliative
Care Referrals
Surgery
#
%
Radiation
#
%
Hem/Onc
#
%
PCP
#
%
Renal
# %
Cardiology
#
%
Pulmonary
#
%
GI
#
%
Other
# %
TOTAL
#
%
Std 4.6 Rehabilitation Services Evaluation
Rehabilitation Services Are Provided: □ Onsite
□ By Referral
Number of pts referred for rehab services1 =
Evaluation
Acceptable
Needs Improvement
N/A
Rehabilitation services onsite
Rehabilitation services by referral
Referral criteria for functional assessment
Referral criteria for professional rehabilitation services
Analysis:
• Strengths, gaps, barriers:
Recommendations for improvement (if warranted):
1 This
standard does not require reporting the number of pts referred, but the info may be helpful data to assist with assessing the adequacy of the services
for the pt population. Data may also help to determine if providers are meeting pt needs by referring appropriate individuals.
Std 4.6 Rehabilitation Services Evaluation
Referral Criteria For:
Acceptable
NI1
• Functional assessment
Number of pts referred for rehab services2 =
• Professional rehabilitation services
1NI
= Needs Improvement
Onsite
By Referral
Acceptable
NI1
PT
□
□
□
□
OT
□
□
□
Lymphedema
□
□
Speech
□
Cognitive
□
Services
Onsite
By Referral
Acceptable
NI1
Pelvic
□
□
□
□
□
Vocational
□
□
□
□
□
□
Prosthetics
□
□
□
□
□
□
□
Pain management
□
□
□
□
□
□
□
General Fitness
□
□
□
□
Services
Analysis/evaluation of rehabilitation services:
• Criteria to trigger referral for assessment +/or rehabilitation
• Strengths, gaps, barriers:
Recommendations + Quality Improvement (if warranted):
2 This
standard does not require reporting the number of pts referred, but the info may be helpful data to assist with assessing the adequacy of the services for
the pt population. Data may also help to determine if providers are meeting pt needs by referring appropriate individuals.
Std 4.7 Nutrition Services Report
Number of pts referred for nutrition services =
Onsite
By Referral
Acceptable
NI1
Nutrition Assessment2
□
□
□
□
Medical Nutrition Therapy Recommendation3
□
□
□
□
Weight Management
□
□
□
□
Nutrition Counseling/Education
□
□
□
□
Management Enteral +/or Parenteral Nutrition
□
□
□
□
Services
Analysis/evaluation of nutrition services:
• Strengths, gaps, barriers:
Recommendations + Quality Improvement (if warranted):
1NI
= Needs Improvement
2Assessment
3Medical
includes screening for potential risks as well as diagnosis of nutritional impairments related to pre-exisiting status, disease and/or treatment
Nutrition Therapy is defined as evidence-based strategies implemented to normalize serum glucose and lipid levels, achieve weight loss or
stabilization, and develop healthy and sustainable eating habits.
Std 4.7 Nutrition Services Report by Medical Discipline
Nutrition services are provided
□ Onsite
□ By Referral
Radiation
Hem/Onc
PCP
Inpatient
Surgery
Other
Nutrition Services
#
Screening and Nutrition Assessment
Medical Nutrition Therapy
Weight Management
Nutrition Counseling/Education
Management Enteral +/or Parenteral
Nutrition
Total Nutrition Service Referrals
%
#
%
#
%
#
%
#
%
#
%
Total
Referrals
#
%
Std 4.7 Nutrition Services Report by Disease Site
Nutrition services
are provided
□ Onsite
Breast
#
%
Screening +/or
Nutrition Assessment
Medical Nutrition
Therapy
Weight Management
Nutrition Counseling,
Education
Management Enteral
+/or Parenteral
Nutrition
Total Nutrition Service
Referrals
□ By Referral
Lung
#
%
Colorectal
#
%
Prostate
#
%
H&N
#
%
Lymphoma
#
%
UGI
#
%
Other
#
%
Total
#
%
Std 4.8 Survivorship Program Report
Survivorship Team:
Available services:
Service #1
Type of Service
Estimated number of patient
participants
Evaluation of services: challenges,
barriers, gaps in resources
Recommendations for
improvement of services
(if warranted)
Service #2
Service #3
Std 4.8 Survivorship Program Report
Survivorship Team: Name (coordinator), Name (physician discipline), Name (social worker), Name (navigator), etc
Available services: nutrition, PT/OT, lymphedema therapy, fitness program, wound/ET therapy, financial counseling, social work, pelvic floor
medicine/sexual dysfunction clinic, support groups, SCPs, fertility counseling, pain management
Service #1
Service #2
Service #3
Type of Service
Cardio-oncology
Survivorship Care Plans (SCP)
Financial Counseling
36 breast cancer survivors received 23 rectal cancer survivors have
12 survivors have received
Estimated number of patient
cardio-oncology consultation +
received SCPs + review within 6
assistance from financial counselor
participants
recommendations
months of curative intent care
Evaluation of services: challenges,
barriers, gaps in resources
Recommendations for
improvement of services (if
warranted)
Pathway successfully implemented Provision of SCP via telemedicine + 9(12) survivors were approved for
for breast survivors; cardiologist
on-site visits has facilitated delivery Medicaid; 5 survivors received
participation limited to 2 physicians of information to survivors +
medication assistance from
caregivers
manufacturer; limited availability of
staff + knowledge; currently
assigned to social worker in
addition to other responsibilities
Expand to other survivor
Expand to other survivors
Obtain approval for financial
populations with site-specific
populations; have SCP document
counselor FTE; ensure opportunity
pathways; increase cardiologist
available in pt portal; develop
for education, training + resources
availability/participation
evaluation for adherence to
for support; refine job description
surveillance recommendations
Std 5.2 Psychosocial Distress Screening Summary
Psychosocial Support Services are Provided:
Number of pts who
have completed
distress screening
Issues identified
by pts
□ Onsite
□ By Referral
Screening scores
<5
>5
Scores > 5 are considered threshold for
moderate to severe distress
(enter number/percent)
Financial
#
%
Insurance
#
Transportation
%
#
%
Pain Symptoms
#
%
Family
Needs
Emotional
#
#
%
Offsite Referral Resources
%
Spiritual
#
%
Mobility
#
%
Other
#
Onsite Referral Resources
□ Mental Health Professional
□ Integrative Therapy
□ Social Work
□ Chaplain
□ Cancer Support Group
□ Food Services
□ Nutritionist
□ Palliative Care
□ Social Security Office
□ Homecare/VNA
□ Financial Counselor
□ ET Therapist
□ Faith-Based Professional
□ Transportation Service
□ Nurse Navigation
□ PT/OT
□ Pain Management Provider
□ Hospice
□ Mental Health Professional
□ Lymphedema Therapist
□ Cancer Support Organization
□ Prosthetics Provider
□ Pain Management Provider
□ Speech Therapist
%
Std 5.2 Psychosocial Distress Screening Summary (2)
Analysis/evaluation of psychosocial distress screening1:
• Strengths, gaps, barriers:
Recommendations + Quality Improvement1 (if warranted):
1
The elements of the required report do not specify analysis and recommendations as described above, but as
per the measures of compliance requirements the process is to be evaluated
Std 8.1 Barriers to Care Report (page 1 of 3)
Report Components
Cancer Barrier Analysis:
Identified barrier
Cancer Barrier Analysis: Barrier
types
Report Details
Access to treatment and symptom support services
Provider, system and patient-related factors have contributed to limited access to radiation therapy treatments and
management of disease +/or treatment related adverse symptoms. The radiation therapy dept hours of operation
are 8am-4pm, Monday- Thursday and Friday 8am- 12pm. The center volumes result in minimal schedule flexibility
that accommodates pt availability esp for pts who continue to work to maintain income and insurance and pts who
depend on availability of family members for transportation or childcare. The number of cancelled and no show
appointments ranges between 20-25%. Occasionally limited appointment and provider availability has made it
necessary for pts to use ED services for symptom management.
Cancer Barrier Analysis: Potential Completion of distress screening during the XRT consultation appointment provides the nurse navigator a timely
strengths
opportunity to assess pt scheduling needs. The availability of Advance Practice + Oncology Certified Nurses (APNs
and OCNs) employed by the Cancer Program offer a potential opportunity for addressing pt symptom management
needs.
Cancer Barrier Analysis:
The analysis was completed through the use of the following resources:
Resources used to complete
1. Review of XRT schedules for cancelled and “no show” appointments over a 4 month period; pts involved were
analysis
contacted to explore factors contributing to these occurrences.
2. Pt satisfaction surveys were reviewed for areas of dissatisfaction
3. Pt demographic information, social history and distress screening assessments were audited to identify individuals
who: were continuing employment; maintained health insurance for themselves and other members of the
family; lived alone, were without social support systems, had childcare or elder care responsibilities; +/or had
transportation concerns.
4. Community resources were explored to identify the availability of transportation services
Std 8.1 Barriers to Care Report (page 2 of 3)
Report Components
Cancer Barrier Analysis:
Resources used to complete
analysis
Resources and Processes to
address barrier
Report Details
5. The providers and staff were surveyed to identify willingness to accept expanded hours of center operation
6. An ad hoc workgroup was formed to assess the financial and operational feasibility of expanded hours of operation
1. The radiation therapy hours of operation were expanded as follows: M-W-Th hrs extended to 8:30pm; Friday 84:40pm and Sat hours implemented 8am-12pm; OTV visits were moved to Wednesday to leverage extended hours
2. Nurse Navigators expanded the intake assessment to include identification of scheduling needs; this info is now
shared with the radiation therapy treatment team and schedulers; transportation and other unique needs are
referred to social work for possible assistance based on available community resources
3. On a rotating schedule, an APN has been assigned to triage and address symptom management issues to decrease
use of ED services; expanded hours of operation have facilitated availability of appointments for pts with symptom
management needs that require in person assessment and management
Outcome Metrics
20-25%
Post Barrier
Reduction
7-10%
12%
4%
Calls to APN for symptoms
Not measured
16/wk
Pt satisfaction with access
50%
80%
Non-productive schedule occurrences (ie empty appointment slots)
2%
4%
Metrics
No show + cancellation rate
ED / hospital admissions for symptoms
Baseline
Std 8.1 Barriers to Care Report (page 3 of 3)
Report Components
Areas for improvement
Report Details
1. Utilize EMR to communicate pt scheduling needs to schedulers as well as documentation that highlights
scheduling limitations for care team
2. Designate specific “non-business hour” appointment times as reserved for pts with scheduling limitations;
identify time limits for holding these appointment times
3. Revise approach to overall scheduling to reduce non-productive clinical time
4. Explore expanded role of nurse navigators and OCNs for pt education re-symptom management, triage and
symptom management
5. Continue to monitor outcome metrics
Reminders
Std 8.3: If you are participating in the “return to screening PDSA”, you do not need to
submit the screening portion of the community outreach report template
• You DO need to submit the prevention portion of the community outreach report template (8.2)
Std 7.3: If you are participating in the “return to screening PDSA”, you do not need to
submit the quality improvement report template
• If you have done a quality improvement initiative in addition to the “return to screening PDSA”,
it couldn’t hurt to take credit and complete the quality improvement report template
Std 9.1: Even if you are participating in the “return to screening PDSA and clinical trial
initiative”, you are still required to complete the clinical trials report template
Source: Return to Screening: Standards, Compliance, and Documentation (facs.org); slide #33 (11/11/21)
Commission on Cancer COVID-19 Accreditation Tracker 2021
Standard
Impact (Yes/No)
Summary of Impact
1.1: Administrative Commitment
2.1: Cancer Committee
2.2: Cancer Liaison Physician
2.3: Cancer Committee Meetings
2.4: Cancer Committee Attendance
2.5: Multidisciplinary Cancer Case Conference
CLP reports given by email.
2Q cancer committee meeting canceled. Updates were given
by email
2Q meeting canceled. Attendance impacted for 3Q due to
physician members attending to COVID-19 needs
Cancer conferences now all virtual. Presentation volume was
impacted during transition period, but is now back to normal.
3.1: Facility Accreditation
3.2: Evaluation and Treatment Services
4.1: Physician Credentials
4.2: Oncology Nursing Credentials
4.3: Cancer Registry Staff Credentials
Registry staff furloughed for 6 months.
4.3: Cancer Registry Staff Credentials
Yes
Registry staff furloughed for 6 months.
4.4: Genetic Counseling and Risk Assessment
Yes
4.5: Palliative Care Services
Yes
4.6: Rehabilitation Care Services
Yes
4.7: Oncology Nutrition Services
Yes
Genetic counseling services were not available for a short
time. Patients were unable to attend counseling sessions.
Some palliative care services were switched to telehealth,
which resulted in a disruption during the transition.
Hiring freeze did not allow us to hire rehab professional as
planned.
Unable to implement launch for new referral process until
February 2021.
4.8: Survivorship Program (2021 phase-in
Standard)
No
5.1: CAP Synoptic Reporting
No
5.2: Psychosocial Distress Screening
Yes
6.1: Cancer Registry Quality Control
Yes
6.2: Data Submission (2020 only)
(Standard retires in 2021)
Yes
Psychosocial distress screening on hold because unable to
safely facilitate screening. One-on-one counseling also
unavailable.
Delays in quality control review because of cancer registry
furloughs.
Delays in data submission because of cancer registry
furloughs.
6.3: Data Accuracy (2020 only) (Standard retires in 2021)
6.4: RQRS Participation (2020 only) RCRS Data Submission (2021)
6.5: Follow-Up of Patients
7.1: Accountability and Quality Improvement Measures
Yes
Yes
Unable to do follow up because of cancer registry furloughs.
Delays in treatment due to all elective procedures being
Yes
canceled April-May 2020.
No
7.3: Quality Improvement Initiative
Yes
8.1: Addressing Barriers to Care
Topic was changed mid-year because original topic was
irrelevant. Completion of QI initiative delayed into 2021.
Retired goal mid-year because it was no longer feasible due to
COVID-19 challenges. Unable to report twice on goal status
Yes
within 2020. Efforts transitioned into addressing COVID-19
barriers.
Originally-planned barrier to address is no longer applicable.
Yes
Efforts transitioned into addressing COVID-19 related barriers.
8.2: Cancer Prevention Event
Yes
8.3: Cancer Screening Event
Yes
9.1: Clinical Research Accrual
Delays in data submission because of cancer registry furloughs.
Yes
7.2: Monitoring Concordance with Evidence-Based Guidelines
7.4: Cancer Program Goal
Delays in data submission because of cancer registry furloughs.
Event canceled for 2020.
Event canceled for 2020.
Required percentage not achieved because several cancerYes
related trials are on hold.