Q. Our site will be completing the Community Needs Assessment in 2018. The last Assessment was not completed in 2015 until October, which is not enough time to complete the requirements for Std 3.1. If our CNA will not be completed until later in 2018, can we choose a barrier from the CNA from 2015?

  1. The years of your survey cycle are probably important here. If you have identified barriers and chosen a barrier for each year, addressed that barrier and can show follow up in the cancer committee minutes, it seems that the intent of the standard has most likely been met. While we would like to be able to answer all questions, this is one that should be directed to the CAnswer Forum. This recent post on the CAnswer Forum might be relevant to your question.

05-17-17, 12:18 PM-Question

Our CNA is due in our last year of our survey cycle but it is about a year process. Will this meet the standard if it's being done but results may not be available before the end of that cycle.

05-17-17, 12:47 PM-Accreditation and Standards staff response

If your last CNA was performed in 2014 and was applied to the standards during this current survey cycle and the 2017 CNA will be completed this year and utilized during the next cycle, it would be acceptable.

Q. We don’t have a social worker, can a Nurse Practitioner or LPN be the psychosocial coordinator?

  1. See page 57 of the 2016 Standards Manual for the information about standard 3.2. This statement is taken from the standard.

“The Psychosocial Services Coordinator on the cancer committee (oncology social worker, clinical psychologist, or other mental health professional trained in the psychosocial aspects of cancer care) is required to oversee this activity and report to the cancer committee annually.”

  1. For Standard 3.3 do you have information about the updated standard? Specifically, they have socialized 50% requirement for 2018 or if you do not meet can have an action plan.
  1. We only have the information that we presented in the webinar. More information will be coming out in January in the CoC Bulletin.
  1. Psychosocial Distress Screening-Did you state info gathered from the distress screening can be incorporated into the Community Needs Assessment?
  1. It is likely that the distress screening will reveal barriers to care that the patient has encountered and are the reason for their distress. This is valuable information for your program to use as a part of the CNA because it reveals barriers that exist and need to be addressed.
  1. Can you show an example of how to calculate the denominator for the SCP's....IE what do you exclude besides Insitu & IV, class of case like 00 or those that have LEFT your system.
  1. There is a formula for calculating percentages at CoC).pdf. (This is on slide 37 of the presentation.)
  1. Does the # of patients that are no shows or refuse the SCP count toward your percent given?
  1. I have posted an answer from the Accreditation and Standards staff that asks a similar question. We suggest you review the CAnswer Forum for other questions/answers related to the one you have asked here.

09-26-17, 03:07 PM-Question

The PAR/SAR asks for # of eligible patients, # of patients refused, # of 'no shows', and # of eligible patients that received SCP's. We track specific exclusions as; # of patients deceased, # of patients without RO Follow up, # of patients that moved, # that had follow up elsewhere. These don't necessarily fall into the categories of 'refused', and 'no shows'. How do we track these?

09-27-17, 04:50 PM-Accreditation and Standards staff response

Patients who pass away before completing treatment are excluded from the numerator and denominator for the survivorship care plan standard. The others you mention, are not excluded from the calculations if they have completed treatment for curative intent. Each program must design their own process for tracking patients who are eligible for survivorship care plans.

  1. Do cancer programs have to use a validated tool for Distress Screening? Or can it be a hybrid of existing validated tools?
  1. See page 56 of the 2016 Standards Manual. The answer included below is taken from this source.

“Tools: The cancer committee selects and approves the screening tool to be administered to screen for current distress. Preference should be given to standardized, validated instruments or tools with established clinical cutoffs. The cancer committee determines the cutoff score used to identify distressed patients.”

  1. For Standard 3.2. It states that all patients receive a distress screening. Would this include patients diagnosed but do not receive any treatment??
  1. CAnswer Forum question similar to yours:

08-22-17, 10:36 AM-Question

We usually assign class of case 00 to the patient's first visit to the hospital where is patient admitted with sign and symptoms and based upon the diagnostic work-up newly cancer diagnose is made. 90% of the time it's a same day visit and pathology report comes after the patient discharge. In addition, to qualify the definition of class of case 00, patient should not return to the facility for any treatment. So technically class of case 00 should be exempt for distress screening.
Please advice. Thanks

08-22-17, 01:26 PM-Accreditation and Standards staff response

No, they should not be excluded. Standard 3.2 requires cancer programs to develop a distress screening process for all cancer patients regardless of class of case. Per the response on February 16, 2017, “The cancer committee must develop the process for screening and how to document that the process was followed. The Psychosocial Services Coordinator should be involved in this process and must provide an annual summary report to the cancer committee.”

  1. If we mail a copy of SCP to patient and asking them to call us back to discuss the SCP, after they review it, but they tell us that they do not wish to discuss the SCP over the phone or in person. Will that count, even though we have reached out to patient several times to discuss the plan/followup?
  1. CAnswer Forum question similar to yours:

10-23-17, 01:48 PM-Question

We have patients that have surgery with our facility. Surgery is the curative treatment, they do not need RO/MO. We try to catch them and offer a survivorship visit and more often than not they refuse to come in. What is the most appropriate next step to take, remove them from our denominator or mail the care plan and review over the phone??

10-24-17, 01:55 PM-Accreditation and Standards staff response

You need to keep these patients in your denominator. The SCP can be delivered at a follow-up appointment with the physician. If you are not able to schedule an appointment you can mail the SCP but you need to schedule a time to review the SCP over the telephone with the patient. There are several questions in the CAnswer Forum referring to similar scenarios, I recommend you review Standard 3.3 questions and answers from 2017.

The CoC will be sending out information about the standard 3.3 in December. Information will be provided throughThe Briefand will be on the CoC website where the standards manual is located.
A brief announcement was put in College publication earlier this month ( More directed communication to accredited programs will be sent soon. Thank you!

Q. For Standard 3.1, do you have any specific documentation examples for what/how to presented at the CoC meeting at the beginning and end of the year? Grids? Number?

A. See the SAR documentation grid in the webinar.

Q. How are cancer programs screening pediatric cancer patients for distress?

A.We suggest that you post this question on the Forum.

Q. Why is CNA listed as discussed each year, when it is only done once every 3 years?

A. The barrier(s) that need to be addressed are identified in the CNA and this discussion takes place each year of the survey cycle.

Q. Which website will the webinar be posted on?

A. The webinar will be posted on the Oncolog and Onco-Nav websites.

Q. many Head and Neck Stage IV cancer patients are still potentially curable. wouldn't they meet criteria for inclusion for SCP's?

A.The cancer committee in your facility will decide if these patients are eligible. Similar questions have been posted on the Forum if you need additional information.

Q.