QASP-VAPHS Cancer Registry.pdf

CANCER REGISTRY SERVICE VAPHS

QSAP

Quality Assurance Surveillance Plan For: VA Pittsburgh Healthcare System Contract Description: VAPHS Cancer Registry Services

1. PURPOSE

This Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract. This QASP explains the following:

• What will be monitored.

• How monitoring will take place.

• Who will conduct the monitoring.

• How monitoring efforts and results will be documented.

This QASP does not detail how the contractor accomplishes the work. Rather, the QASP is created with the premise that the contractor is responsible for management and quality control actions to meet the terms of the contract. It is the Government’s responsibility to be objective, fair, and consistent in evaluating performance.

This QASP is a “living document” and the Government may review and revise it on a regular basis. However, the Government shall coordinate changes with the contractor.

Copies of the original QASP and revisions shall be provided to the contractor and Government officials implementing surveillance activities.

2. GOVERNMENT ROLES AND RESPONSIBILITIES

The following personnel shall oversee and coordinate surveillance activities.

a. Contracting Officer (CO) - The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall also ensure that the contractor receives impartial, fair, and equitable treatment under this contract.

The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

Organization or Agency: Department of Veterans Affairs, VISN 4

b. Government Point of Contact (POC) - The POC is responsible for technical administration of the contract and shall ensure proper Government surveillance of the contractor’s performance. The POC shall keep a quality assurance file. The POC is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

3. PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

Cancer Registry Standards

A. 100% of cases are abstracted within 4 - 6 months of the patient’s first contact with the program.

B. 80% follow-up rate is maintained on all patients from the Cancer Registry reference date. Within 15 years C. 90% follow-up rate is maintained on all patients diagnosed within the last 5 years.

D. Data is submitted to the VA, Cancer Committee and to the VA Central Cancer Registry upon request prior to or within deadlines.

E. Data re-submitted, e.g. to the NCDB and to all other requestors, e.g. VA Central Cancer Registry on cases diagnosed on or after the Cancer Registry reference date meet the quality criteria and resubmission deadline specified in the VA Central Registry.

F. Monthly reviews are conducted of the quality of Cancer Registry abstracting through 100% of the annual analytic caseload.

The plan shall also identify the activities to be evaluated and shall set the benchmarks for required accuracy to meet all ACOS cancer program standards; and shall include the review of all pathology/radiology/Computerized Patient record System (CPRS) and Vista Imaging reports.

G. Education/Certified Oncology Data Specialist (ODS-C): The contractor shall show proof that those providing abstracting services are Certified Oncology Data Specialist (ODS-C) through the National Cancer Registrars Association. Contractor personnel functioning under this contract shall be certified by the National Cancer Registrars Association. The Contractor shall verify its personnel’s current certification status with the National Cancer Registrars Association and shall provide evidence of certification with their proposal submission. Ongoing cancer-related education enhances knowledge and skills. All Contractor Cancer Registry staff who perform case abstracting must:

H. Hold a current Certified Oncology Data Specialist (ODS-C) credential. The Certified Oncology Data Specialist (ODS-C) credential is granted through the National Cancer Registrars Association, which provides details on eligibility, testing, and recredentialing. High-quality Cancer Registry data are essential to accurately access treatment outcomes and patient survival.

Successful operation of the Cancer Registry requires credentialed staff that is trained and knowledgeable in all aspects of oncology data collection and case abstracting. Abstracting is defined as coding and entering patient- and disease specific information into the Cancer Registry database. Certified Oncology Data Specialist (ODS-C) apply knowledge obtained from formal education and work experience to correctly interpret and code cancer diagnosis, stage, treatment, and outcomes information for each case that is seen at the VA Pittsburgh Healthcare System CoC accredited program that meets CoC reporting requirements.

I. The case abstracting responsibilities of the Certified Oncology Data Specialist (ODS-C) are documented by the Contractor.

J. In addition, the Contractor shall provide documentation upon request and annually that all members of their Cancer Registry staff shall participate in one cancer-related educational activity other than cancer conferences. Certified Oncology Data Specialist (ODS-C) Contractor staff participate in at least one cancer related educational activity other than cancer conferences at the local, state or national level; this education could include topics in the following areas: Advances in cancer diagnosis and treatment, changes in cancer program standards and changes in data collection requirements. Each year, all Contractor staff that work on this contract shall participate in 1 cancer-related educational activity other than cancer conferences; all members of the Contractor’s Cancer Registry staff shall participate in ongoing cancer-related education at the local, state, regional, or national level. All Contractor Certified Oncology Data Specialist shall maintain NCRA Credential and shall participate in a cancer related educational activity each year.

5. PERFORMANCE REQUIREMENTS SUMMARY

The contractor service requirements are summarized into performance objectives that relate directly to mission essential items. The performance threshold briefly describes the minimum acceptable levels of service required for each requirement. These thresholds are critical to mission success. The quality standard is what is expected for a satisfactory CPARS rating. Less than quality standards would result in a possible cure notice and contract termination. All reports and pro-forma invoices submitted within 7 days of the end of the reporting period for POC review.

TASK SECTION REQUIRED

SERVICE

(Performance Requirements)

QUALITY

STANDARD

STANDARD

(Performance Standards)

METHOD OF

SURVEILLANCE

(Quality Assurance)

1 A Case finding 100% See Section A Case Finding of the PWS.

VA POC

Monitoring

Monthly report

2 C Case Abstracting

100% See Section C, Case Abstracting and Coding of the

PWS.

VA POC

Monitoring

Monthly report

3 D Cancer Registry Follow-up : (i) All Patients and

(ii) Patients are diagnosed within last 5 years.

100% See Section D, Follow-up of the PWS

VA POC

Monitoring Monthly report

4 E Data Submission to National Cancer Database (NCDB) and State where applicable.

100% See Section E Reporting Cancer Data/Transmission of Data of the PWS.

Annual Report

5 F Resubmission of Data

100% See Section F- Rapid Cancer Reporting System (RCRS) of the PWS.

Ongoing surveillance.

Annual report

6 I Quality checks of abstracting and follow-up by vendor of its own work

100% See Section I- Rapid Cancer Reporting System (RCRS) of the PWS.

Ongoing surveillance.

Monthly report

7 Invoicing 100% Monthly Invoice Submittal. Monthly compliance assessment

8 G Licensing.

Registration and certification

100% See Section G of the Cancer Registry Standards- Education/Certified Oncology Data Specialist (ODS-C) of the

PWS.

Ongoing surveillance.

Annual report

9. G Mandatory Training and Continuing Education/ Competency

100% See Section G. Continuing Education/Competency of the

PWS.

Ongoing surveillance.

Annual report

10 H Privacy, Confidentiali ty and

HIPAA

100% See Section H. VA- Specific Privacy Training of the PWS.

Ongoing surveillance.

Annual report

6. Methods of QA Surveillance The POC shall use the surveillance method listed below in the administration of this QASP. The POC shall assess contractor performance as each invoice is submitted using the Quality Assurance Worksheet. The POC shall maintain the Quality Assurance Worksheets in the contract files and utilize them for CPARS reporting.

a. PERIODIC INSPECTION. The POC and/or Contracting Officer will conduct monthly random inspections of performance as indicated by the deliverables of the contract.

b. MONTHLY INVOICE REPORTS

Sample Discrepancy Report: