654 VASNHCS-QASP-CancerRegistry.pdf

Quality Assurance Surveillance Plan

Task ID Indicator Standard

Acceptable

Quality

Level

Method of

Surveillance

Cancer

Registry

Tasks

Records maintenance, including completion of abstraction

Tumor registry services are conducted using

VISTA, CPRS, and

Oncotrax systems;

services include chart abstracting, case finding, case rejections and consult support services

98%

Run monthly reports through

VISTA identifying cases, unresolved issues

Case abstracting and coding

Complete abstract must be completed within 6 months of the date of diagnosis for those cases assigned a confirmed accession number

95%

Within 6 months of date of diagnosis case abstract must be completed; run reports to review exceptions

Computer data entry (electronic patient record/VISTA

Oncology package) of all cases

At minimum, 3 years’ experience with VISTA, CPRS and Oncotrax software. Working knowledge of internet access, Microsoft excel, word and outlook

95%

Completion of all mandatory training and required privacy, security training

Meeting reporting requirements of statewide cancer registry, the

American

College of

Surgeon’s

Commission on

Cancer and the

VA Central

Cancer Registry

Within 6 months of date of diagnosis registrar must complete a case abstract

Monthly

Abstracting:

100% compliant within 6 months of diagnosis.

Follow-up:

1) Database from 1984:

80% or higher.

2) Database for last 5 yrs.: 90% or higher

Cancer registrar will run incomplete lists and follow-up rate lists every month to show cases and their status

Task ID Indicator Standard

Acceptable

Quality

Level

Method of

Surveillance

Maintaining credentials through the

National Cancer

Registrar’s

Association

Appropriate credentials must be current throughout the contract;

includes National

Cancers Registrar certification; if other credentials pertinent to the contract it must be supplied also, e.g., RHIT/RHIA from

AHIMA

100%

Reviewed by COR at time of recorded expiration date for renewal action

Cancer

Registry

Tasks

Maintaining a cancer database that can be used to evaluate the efficiency of cancer therapy in the region as well as provide a base for epidemiological studies

AJCC stage forms are added to all applicable cases for reporting to

NCDB, NYS and

VACCR

95%

Completed cases are compared to final entry data

Maintaining patient and records confidentiality in accordance with the Privacy Act of 1974, complying with the terms of VA computer access security agreement, and other applicable government regulations

Must have the required privacy and cyber security mandatory training

100%

Review training certificates at expiration dates to determine if renewed

H. Methods of QA Surveillance:

Various methods exist to monitor performance. The COR may use the surveillance methods listed below in the administration of this QASP.

a. PERIODIC INSPECTION: Evaluation of outcomes on a periodic basis. Inspections may be scheduled

[Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.

1, 2, 3, 4, 5, 6, and 7

b. RANDOM SAMPLING: Designed to evaluate performance by randomly selecting and inspecting a sample of cases.

1, 2, 3, 4, 5, 6, and 7