QASP-Cancer Registry 02.docx

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Attached to
R702--Cancer Registry Services Federal contract opportunity
Solicitation number
36C26121Q0647
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 21

About this file

This document outlines a quality assurance surveillance plan for cancer registry services. The plan details seven key tasks for the contractor including records maintenance, case abstracting and coding, computer data entry, meeting various reporting requirements, maintaining credentials, maintaining a cancer database, and ensuring patient confidentiality. Performance will be evaluated on a monthly basis for most tasks to ensure abstracting is completed within six months of diagnosis and follow-up rates meet specified thresholds. The contractor must also have the required privacy and cybersecurity training. Methods of surveillance include periodic inspections that may be scheduled or unscheduled as well as random sampling of cases.

A pre-solicitation notice provides details for a forthcoming solicitation seeking a contractor to provide cancer registry services to the VA Southern Nevada Healthcare System in Las Vegas. Interested parties are advised to review all documents carefully and submit any requests for information or clarification. The solicitation is scheduled for release on May 4, 2021 with quotes due by May 12, 2021. The requirement is being conducted by the Department of Veterans Affairs Veterans Health Administration VISN 21.

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Past Performance Surveys.docx DOCX document
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Contractor Security Requirements.docx DOCX document

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Quality Assurance Surveillance Plan

Task
ID
Indicator
Standard
Acceptable Quality Level
Method of Surveillance
Cancer Registry Tasks
1
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
2
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
3
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
4
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

5
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
6
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
7
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

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