Tumor Registry Services PWS-QASP.docx

Performance Work Statement/QASP Medicine Service Tumor Registrar Services

I. Objectives/Requirements:

The objective is to procure Tumor Registrar Services to assist in the reduction of caseload backlog. The WPB VA cancer registry is now staffed by three full time Cancer Registrars (2 Certified Tumor Registrars (CTR’s). The facility’s average caseload is approximately 900 cases annually. The American College of Surgeons (ACOS) also requires participation in Standard (6.4)- Rapid Quality Reporting System by all facilities. This requires a monthly timeline for case submission. Based on previous caseload history we estimate a current unabstracted caseload of approximately 2,400.

II. Tasks and Deliverables:

The Contractor shall provide all necessary staffing and resources needed to properly maintain the WPB VAMC Cancer Registry database services in accordance with 100% of the current American College of Surgeons Commission on Cancer Registry standards and Veterans Health Administration (VHA) Cancer Registry requirements. VA reportable list will be shared with the receiving contractor after award. The Contractor shall have current experience managing a Cancer Registry program within the last two years and have recent experience with the American College of Surgeons (ACOS) Commission on Cancer (COC) Standards. The duties and responsibilities of the Contractor shall include but are not limited to:

1.) Case Abstracting and Coding – Abstracting is defined as coding and entering patient and disease specific information into the Veterans Administration VistA Cancer Registry database or other databases as identified within this statement of work, e.g., the Rapid Quality Reporting System (RQRS database). The Contractor shall provide complete, accurate quality abstraction services and shall ensure that all cases are cleared (within pre-established timeframes) in terms of passing edits required by the VA Central Cancer Registry or by the American College of Surgeons Commission on Cancer, e.g., National Cancer Database edits, Vista Oncology package edits, Gen-edits, Program edits, etc. The Contractor shall abstract oncology cases with 100% accuracy and shall ensure that all Commission on Cancer requirements/standards are met. Contractor is responsible to transcribe and interpret information from patient records regarding treatment provided to new cancer patients annually using the approved Veterans Administration (VA) abstracting software program (currently the Vista-Oncotrax). The Contractor shall review and abstract the cancer patient’s medical record on an ongoing basis in compliance with the industry standards of the North American Association of Central Cancer Registries (NAACCR), National Cancer Institute Surveillance, Epidemiology and End Results Program (SEER), World Health Organization International Classification of Diseases for Oncology (ICDC), American Joint Commission on Cancer (AJCC) Staging Manual Criteria, VA Central Cancer Registry (VACCR) Reportable List, American College of Surgeons/Commission on Cancer (ACOS/CoC) and the WPB VAMC Cancer Registry criteria. The contractor will be a Certified Tumor Registrar (CTR), and produce and provide proof of current credential status, to provide abstracting services. The Contractor shall abstract cases within 4-6 months of the cancer diagnosis. The Contractor shall return a monthly list of case abstracts completed along with the Contractor's monthly invoice to the COR and POC.

2.) Rapid Quality Reporting System: The Contractor shall monitor the quality of the Cancer Registry data. The Contractor shall monitor the facility's performance based on the COC performance indicators, using the COC reporting tools for the Rapid Quality Reporting System (RQRS) if requested by the facility, when facility does not have subject matter experts. The Contractor shall keep the Program Manager, the Cancer Liaison Physician, and the Chair of the Cancer Program Committee and the Cancer Program Coordinator advised of the performance status as requested by the above-mentioned staff, and no less than once monthly. (RQRS is a real-time data collection program to assess hospital-level performance using National Quality Forum (NQF) endorsed quality of cancer measures).

III. Quality Assurance Surveillance Plan (QASP)

1.) The Contractor shall provide quality work, complete work, and accuracy as evidenced by meeting Commission on Cancer, National Cancer Data Base, National Cancer Registrars Association (NCRA) and VA Central Cancer Registry standards and requirements. The Contractor shall perform a 100% quality assurance review on all newly abstracted cases for compliance noting any deficiencies or non-deficiencies prior to the submission of the invoice. The Contractor shall institute a Cancer Registry Quality Assurance Plan/Program to evaluate the quality of 100% of their staff s Cancer Registry data and 100% of their staff s Cancer Registry activities done on behalf of the WPB VAMC. The Contractors quality assurance plan shall do the following:

Set the review criteria

Set the quality control timetable

Specify the quality control methods, sources, and individuals involved

Specify the measures that require 100%

2.) The Contractor shall conduct monitoring at least once monthly and shall send their Quality Assurance Surveillance Plan (QASP) report findings to the Cancer Registrar monthly, at a minimum. The QASP report findings should also include the Contractor s process for conducting monthly random case finding audits and include a sample of the audit findings to demonstrate that all eligible analytical cases are reviewed and processed. The Contractor shall send report findings back to facility Cancer Registrar and Administrative Officer monthly and upon request as applicable. Monthly abstracting quality control audit checks shall be performed on 100% of cases abstracted by the Contractor s staff to ensure abstracts are 100% edit and error free prior to invoicing. Reports shall reflect the Contractor’s process for error corrections for all tasks performed by the Contractor’s staff and all tasks as required by the American College of Surgeons-Commission on Cancer for full accreditation; all errors identified either by the Contractor or by an applicable Government representative within one business week. The Contractor shall monitor activity and shall ensure all abstracting duties performed are performed by a Certified Cancer Registrar. The Contractor shall provide written reports at least once monthly and upon request to the Cancer Registrar and/or applicable Administrative Officer and take corrective action on any areas that fall below the measures specified in the QASP.

3.) The Contractors quality assurance plan shall do the following:

Set the review criteria Set the quality control timetable Specify the quality control methods, sources, and individuals involved Specify the measures that require 100% surveillance.

Specify the measures that will be validated on a random basis.

4.) QASP required activities include but are not limited to:

Abstracting timeliness Accuracy of abstracted data that includes but is not limited to:

Class of Case Primary Site Histology AJCC Stage Collaborative Stage First Course of Treatment Follow-up information, including Date of First Recurrence, Type of First Recurrence, and Cancer Status

The percentage of information coded as unknown (usually coded as 9 or a string of 9s)

When required, Cancer Registry data submitted to the National Cancer Data Base (NCDB) shall meet the established quality criteria included in the annual NCDB. The NCDB data submission, correction of data errors, and resubmission of corrected data shall be accomplished seven days of receipt. Required accuracy, at this point, is 100%.

All other standards as outlined in the most current edition of the ACOS Commission on Cancer manual are met or exceeded.

The Contractor performance shall be evaluated, and deductions applied if performance is found deficient as per Quality Assurance Surveillance Plan as follows as required to maintain data and performance quality.

5.) Education/ CTR Certification: The contractor shall show proof that those providing abstracting services are Certified Tumor Registrars 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 performs case abstracting must:

Hold a current Certified Tumor Registrar (CTR) credential. The CTR credential is granted through the National Cancer Registrars Association, which provides details on eligibility, testing, and re-credentialing.

High-quality Cancer Registry data is 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 data base. Certified Tumor Registrars apply knowledge obtained from formal education and work experience to correctly interpret and code cancer diagnosis and stage treatment and outcomes information for each case that is seen at the WPB VAMC that meets COC reporting requirements. The case abstracting responsibilities of the CTR are documented by the Contractor. In addition, the Contractor shall provide documentation upon request and annually that all members of their Cancer Registry staff are maintaining their CTR status this requires 20 CEUs every 2 years as in accordance with industry standards. Per the Commission on Cancer Standards, full-time and part-time registry staff for whom annual education is required are:

CTR staff

Contract CTR staff who are contracted to work for 3 or more consecutive months during the calendar year, regardless of the number of hours worked.

Management or supervisory personnel

This education could include topics in the following areas:

Advances in cancer diagnosis and treatment Changes in cancer program standards Changes in data collection requirements

Educational activities that can be used to fulfill the standard include, but are not limited to, the following:

A cancer-related lecture offered by the program (local activity) A face-to-face meeting or workshop Local involves 1 program or facilities located in 1 city (local activity) State involves 1 state (state activity) Regional involves more than one state organization working collaboratively to develop the workshop.

Agendas and meeting notices indicate the collaborative effort (regional activity)

National is sponsored by a national organization and targeted to a national audience (national meeting)

A video conference (local activity)

A webinar (local activity)

A Web-based training module (local activity)

Journal-based articles that offer continuing education credits (local activity)

Educational activities exclude patient management cancer conferences in any format. National organizations that sponsor national meetings include:

American Health Information Management Association (cancer-related educational activities)

Association of Community Cancer Centers

Commission on Cancer

National Cancer Registrars Association

National Comprehensive Cancer Network

North American Association of Central Cancer Registries

Florida Cancer Data Systems

Florida Cancer Registrar’s Association

VA-Specific / Privacy Training - The contractor shall establish a VA Talent Management System account for completion of mandatory VA training. Each CTR shall complete the following courses on an annual basis in order to sustain access to the VA network:

DVA-002 Privacy and HIPPA

DVA-003 Privacy and Information Security Awareness and Rules of Behavior

Computerized Patient Record System (CPRS) in VISTA. The VA will provide contractor with electronic access to CPRS for use by the Certified Tumor Registrars. Contractor employees are responsible to access the system a minimum of once every ninety (90) days. Failure to access VA system at least once every ninety (90) days will result in the contractor’s employees being locked out of the VA system. The VA will provide Contractor with remote access to the VA Network and Computerized Patient Record System (CPRS) in VISTA. It is expected that electronic access will be done monthly by Contractor s abstracting personnel.

Vista-Oncotrax System Applicable system software functionality training will be provided by VISN Cancer Tumor Registry (CTR) staff as needed. Prior to commencement of work, the Contractor and Contractor staff shall have a working knowledge and competencies required for effective utilization of the VA abstracting software programs and computer hardware. Work will begin within 30-60 days from date of contract award.

Security Applicable staff background information checks and VA systems training, and certifications will be required before system access is granted by the Veterans Service Center (VSC) and the local facility Information Security Officer (ISO) prior to commencement of work.

The contractor shall submit or have their employees submit the following required forms to the COR:

Optional Form 306, Declaration for Federal Employment Self Certification of Continued Service Standard Form 85, Page 6 (Authorization for Release of Information) VA Form 0710, (Authorization for Release of Information) Contractor/Employee Fingerprinting Request Form #2 (This form is provided by the COR, and must be presented to a VA Medical Center for fingerprinting) PIV Sponsorship Form #3

Request for VPN Access. This is a self-enrollment portal located at https: //vaww.ramp.vansoc.va.gov/selfservice/pages/RAUserDetails.aspx?val=WTJlLcOoiqU=

CERTIFICATION/ Logs of monthly work completion

The Contractor shall prepare and submit to the WPB VAMC Cancer Registrar & medical facilities POC a Certificate of work completion with monthly invoices. The Certificate shall, as a minimum, contain the following:

Accession/Sequence Number of Cases/ work completed

Name of contract staff completing the case/work.

Date of First Contact

Date of Diagnosis

Date case/ work was completed

Comments from contract staff as needed

CONTRACTORS RESPONSIBILITIES

Contractor will be responsible for providing onboard documentation, Information Security, Rules of Behavior, Privacy Training, and completing the WPB VAMC VPN requests for computer access for each CTR who will be providing work under the contract.

NATIONAL HOLIDAYS

The 10 holidays observed by the federal Government, i.e., New Year’s Day, Martin Luther King s Birthday, Memorial Day, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving, and Christmas and any other specifically declared by the President of the United States to be a federal holiday. There is no expectation that the contractor will work during these recognized Holidays. WPB VAMC will certify deliverables received, not contractor hours, and therefore this paragraph is provided for vendor information only.