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July-August 2020

The Evolving Cancer Registry Requirements — A Look at How Health Care Organizations Can Best Prepare for ACoS Audits
By Keith Loria
For The Record
Vol. 32 No. 4 P. 26

As the Commission on Cancer (CoC) surveys for cancer registry processes have evolved over the years, so too have the roles and responsibilities of certified tumor registrars (CTRs).

Key members of the cancer committee, CTRs carry distinct responsibilities, primarily surrounding management of the cancer registry data. However, they are no longer solely responsible for ensuring compliance with the CoC standards, as often occurred historically.

“Responsibility for oversight of the cancer program and adherence to the standards lies with the cancer committee as a whole and this responsibility has been defined in greater detail with the most recent version of the cancer program standards,” says Jennifer Zahn, senior director of oncology data services with Ciox.

With the release of the Optimal Resources for Cancer Care, which became effective in January, significant changes have been made, with a greater focus on impacting patient outcomes.

Even the language surrounding “surveys” has changed, Zahn says, noting they are now referred to as “site visits.” Also, the former Survey Application Record (SAR) has been replaced with the Pre-Review Questionnaire (PRQ).

Still, Suzanne Neve, RHIA, CTR, director of cancer registry at Medical Record Associates, says that nine times out of 10, the cancer registrar is the one who facilitates the audit for an organization.

“In my experience, the cancer registrar is usually the person who coordinates the site visit with the surveyor, enters the data into the PRQ, and contacts each department to ensure that the standards that pertain to each department are accurately completed,” Neve says.

Linette Kallaos, MS, RHIA, CTR, an adjunct instructor at the University of Cincinnati’s Clermont campus, says proper data maintenance is essential, noting that the CoC requires cancer programs to produce three years of information be reviewed during an audit. (A new audit process begins the day after the previous audit ends.)

“The audit process for a cancer registry revolves first around the PAR [Program Activity Record] and then the SAR as a landing place for cancer program documentation,” Kallaos says. “The SAR is reviewed in great detail by the CoC surveyor the day of the ACoS [American College of Surgeons] audit.”

Preparing for Audits
Because the current standards are so new, many organizations are still in the process of trying to digest the changes and determine how best to shift their processes in order to be compliant.

Patty Sheridan, senior vice president of real world data market development for Ciox, says those facilities undergoing site visits this year will be evaluated under the previous 2016 standards, while the new 2020 standards will be applied to those with a site visit scheduled in 2021 or later.

“Understanding under which set of standards they will be evaluated on and which years will be reviewed is key for those facilities undergoing review during this transitional time,” Sheridan says. “Moving forward, some of the best ways to prepare are ensuring the cancer committee is fully engaged, developing a yearly schedule to ensure all required tasks are addressed in a timely manner, assigning strong coordinator members with clearly defined roles to distribute the responsibility of standard oversight, utilizing working subcommittees to address challenging areas, and taking advantage of the education provided by the CoC regarding the new standards and best practices.”

To best prepare, Sheridan recommends registrar leaders remain as educated as possible on the future requirements and connect with colleagues for advice on the best practices.

Neve believes health care organizations should approach each day as though an audit was scheduled for the very next day. By adopting this strategy, the mindset is always on the standards. She suggests that organizations focus on being organized and detail oriented, a tactic that will make the auditing process go much smoother.

“Keep either a binder or folders on your computer. Make a folder for each standard and populate the appropriate folder with the necessary information for the audit,” Neve says. “Also keep up to date with entering in your progress into the SARs. I would always enter pertinent information into the SARs following a cancer committee meeting. This way the information is fresh in my mind.”

Maintain a spread sheet that lists what needs to be completed every quarter and report to the cancer committee at each meeting, Neve says. Doing so will keep the key players accountable for their specific standard related to the survey process.

Zahn says the use of subcommittees and workgroups allows cancer committees to more effectively meet the requirements. “A great deal more work can be accomplished in a small group setting, so shifting tasks to these subcommittees allows for greater efficiency and the ability to address many requirements simultaneously,” she says.

Most experts agree that it’s best to start preparing for the ACoS audit early, meaning once the three-year cycle has ended, it’s time to start thinking about the next one.

“A registrar will experience less anxiety about the ACoS audit by continually adding documentation to the PAR or SAR throughout each year,” Kallaos says. “Another preparation tip is to have a mock survey. Mock surveys and program assessments are offered by cancer registry consulting services to evaluate a program’s preparedness prior to the actual CoC survey.”

Kallaos also recommends designating one person to take the lead in organizing the required information for the audit. A “point person” is necessary, she says, so that if there are questions or data submissions from the different program areas, a single contact name and phone number or e-mail address is available.

“In addition, it helps to be familiar with the information that is required by the PAR/SAR as these records are lengthy and a tremendous amount of information is needed for a complete record,” she says. “A three-year continuous effort to add and update information to the PAR/SAR is also recommended so that a cancer registry is well prepared for the audit.”

To help with all these efforts, the CoC provides several resources, such as The Cancer Program News e-newsletter, the CAnswer forum, and regular webinars to support accredited programs.

Staying Ahead of the Curve
Considering that frequent change is one of the constants within the oncology world, health care organizations must stay nimble enough to adapt to evolving regulatory and compliance requirements. For example, Sheridan says cancer registrars must keep up with yearly changes to data collection rules, treatment information, and multiple other requirements.

“In the cancer program space, requirements change rapidly with the advent of new treatments, technology advances, and the evolving needs of patients,” she says. “Keeping current with what is coming next, strong communication among the team, and the willingness to be flexible and inventive are all methods to remain adaptable.”

Kallaos says organizations that have a good understanding of current regulatory and compliance requirements are able to adapt more quickly to any subsequent changes.

“Also, an organization that has enough depth to keep up with evolving regulatory and compliance requirements will fare better when changes surface in health care,” she says. “A supportive cancer committee plays a vital role in whether or not a cancer program is able to adapt to changing regulatory and compliance requirements. Likewise, a supportive cancer committee chair is able to lead a cancer committee to accept change and meet any newly developed standards.”

In that regard, Neve believes success in this area stems from listening to the cancer registrar.

“The cancer registrars usually know what’s going on in the industry months prior to the organization,” she says. “Since most requirements don’t always go into effect immediately, it is important to be proactive and start phasing in those regulatory and compliance requirements immediately. This way you won’t be scrambling at the last minute. Again, organization comes into play here.”

However, administration can often be a challenge. The cancer registry is not a revenue-based department; therefore, resources are not readily available. However, according to Neve, the cancer registry is a major part of the ACoS approvals process. Without the registry, the facility would not be able to become an approved program, she notes.

Dealing With Challenges
Zahn believes the biggest current accreditation-related challenges are becoming familiar with and understanding those areas that have changed in the 2020 standards and identifying how best to implement new requirements.

“While most of the new standards were effective as of January 2020, several of the most challenging, such as those related to the Operative Standards for Cancer Surgery, are phase-in standards with implementation guidelines yet to be determined by the CoC,” she says. “This allows programs some additional time to plan for how best to address these new requirements.”

In the wake of the COVID-19 pandemic, cancer programs are facing significant challenges related not only to patient care and support but also to the disruption of activities such as attending multidisciplinary cancer conferences and cancer committees. In response, the CoC has stated that the cancellation or postponement of required meetings and/or changes to patient care due to COVID-19 will not impact accreditation status.

However, Sheridan says documentation of these events and the reasoning behind them will be required for future site visits. Facilities may also want to consider discussing these events at the next cancer committee meeting to ensure there is adequate supporting documentation to explain any voids.

Preparation for an ACoS audit is time-consuming—plus the time it takes to prepare is time away from the many other tasks that a cancer registrar must manage each day.

Kallaos also notes challenges associated with outside data collection and communication. “A cancer registry collects data for the PAR and SAR and those data are compiled by the Tumor Registry and the other areas of the cancer program such as therapy services and dietary,” she says. “It is often a challenge to remind each department of their responsibility with the CoC standards and to make sure that the appropriate cancer committee members understand their role in submitting proper documentation for the audit.”

Additionally, communication between all staff involved with the audit is crucial. The audit encompasses many individuals who must have a general understanding of the process and its importance to the cancer program.

“Preparing for the audit is an enormous task that uses a lot of cancer program resources,” Kallaos says. “It’s really about finding an organized and efficient way to collect the required data so it can easily be entered, first into the online PAR and then the SAR. Facilities that have a good plan in place when beginning the ACoS audit process will be the most successful on the day of the survey.”

— Keith Loria is a West Virginia–based freelance writer.