CLAXTONHEPBURNMEDICALCENTER

MEETING:Cancer CommitteeMINUTE SUMMARYPage 1 of 2

DATE:April 28, 2010

CALL TO ORDER: 12:00 p.m.- 1:00p.m.PRESIDING:Alka Srivastava, M.D.

MINUTES:Kay Zimmer

PRESENT:Kay Zimmer, LMSWCarol Lytle, Tumor Registrar JJ Mahany, RPA-CKaren Kantor, DO Alka Srivastava, MD

Michele Pelusi, CO CoordinatorGreg Guimond, PharmacistJerry Sheppard, Director/CTCNicole Zeledon, RN John Gebert, MD

Lucille Alston, MDJeanne Raven, RNJoanne Todd, Director/Med Records

ABSENT: Adam, Jarrett, CMO/MDLaura Gregory, ACSKathy Beauchamp, NM/Med SurgChristopher Brandy, MD Juan Harris, MD

Ali Gharagozloo, MD

EXCUSED:Vicki Perrine, VP/Clinical ServicesLeah Neely, Director/PI

PROBLEM/TOPIC / CRITERIA/DISCUSSION / RESPONSIBLE PARTY / ACTION / FOLLOW-UP
Roll Call / Roll call established a quorum was present to conduct business.
Approval of Minutes / The minutes from the meeting. held on January 26, 2010 were presented for review and approval. / Alka Srivastava, MD / Motioned by Jerry Sheppard, seconded by Dr. Lucille Alston and carried to approve the minutes as written.
Patient Navigator / Kay Zimmer has taken on the additional role as Patient Navigator upon the departure of Kim Salton, RN / Jerry Sheppard / None
Annual Goals- Standard 2.5 / Clarification of goals
Community Outreach: May Skin Screening to be completed by the end of May, Educational Panel, to be completed by end of 2010 and Pink Ribbon Campaign, which will end in October 2010. The Campaign will increase awareness and education for breast cancer and the importance of mammograms and will culminate in a walk event in October. The measure for these events will be the completion of each.
Quality Assurance: Patient Navigator will see all new patients at the CancerTreatmentCenter at a rate of 90% compliance starting May 2010. A spreadsheet will be used to measure the goal. This will be an ongoing process that will be evaluated at the end of December 2010. / Jerry Sheppard / These goals will be evaluated in the last quarter meeting.
Community Outreach, Standard 6.2 / See attached / Michele Pelusi / None
Standard 7.1 / Education conference update: A conference on Melanoma is planned for the end of June or early July. The conference will be presented by Judy Murphy, PA, Dr. Alka, and Dr.Yitta. The talk will include diagnosis, AJCC staging, and evidence based treatment guidelines based on diagnosis and stage. / Jerry Sheppard, Director/CTC / None
Quality Improvements, Standard 8.2 / 1)Develop a timeout process for bone marrow biopsies done at the CancerTreatmentCenter.
2)Patient Navigator will see all new patients at the CancerTreatmentCenter
3)Fall Prevention –this is a hospital goal which affects our patients at the CancerTreatmentCenter / Jerry Sheppard, Director/CTC / None

MEETING: Cancer CommitteePage 2 of2

DATE: April 28, 2010

PROBLEM/TOPIC / CRITERIA/DISCUSSION / RESPONSIBLE PARTY / ACTION / FOLLOW-UP
AJCC Staging Audit, Standard 4.3 / See attached / JJ Mahany, RPA-C / JJ will report out on this standard every quarter for the previous quarter
NCDB Data / Data was released to the NCDB / Jerry Sheppard, Director/CTC / None
Cancer Registry Update / Carole Lytle went to the national meeting. In 2011 one major change will be real time abstracting, as soon as the pathology is completed. Also, quality of care, monitors, policies, procedures, and documentation of quality were covered. It was impressed that staging should be done ASAP before any treatment is given, including both clinical and pathological stage. Dr. Alston expressed the difficulty with getting clinical stage in some cases. / Carol Lytle, RN, CTR / Cancer Registry will continue to closely follow the recommendations of the Commission on Cancer
Cancer Registry Policy / See Attached / Carol Lytle, RN, CTR / None
Standard 8.1 / See Attached studies – The rate of compliance for the Colon Cancer study was 62% compliance with the standard of having at least 12 regional lymph nodes removed and pathologically examined for patients with resected colon cancer which is lower than the last study. Dr. Alston stated that if 12 lymph nodes are not found the pathologist needs to state that they looked for them actively. It was recommended that we should be proactive and work on increasing this percentage. The pathologist stated that it is difficult to find the lymph nodes. The Sentinel Node in Breast Cancer study is also attached with limited results due to no Axillary Nodes or Sentinel Lymph Nodes being found on pathology. / Carol Lytle, RN, CTR / It was recommended that we bring the results of these studies to the department of surgery to review them. Jerry Sheppard made a motion and Michele Pelusi seconded the motion. / Continue discussion after the department of surgery reviews the results of the studies.
Adjournment / The meeting was adjourned at 1:03pm. Next meeting to be held July 28, 2010 at 12:00 pm in Conference Room A&B. / Alka Srivastava, MD / None

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Alka Srivastava, M.D., Chair/Cancer Committee Date Christine Richardson, Office Manager, Recording Secretary/CTCDate