DIVIDE AND CONQUER Distributing Responsibility for Accreditation Requirements

*Note, this chart is not a substitute for reading the requirements detailed in Cancer Program Standards: Ensuring Patient-Centered Care

(2016 Edition). Each cancer committee coordinator and member must review the standard for which he or she is responsible and demonstrate

compliance as required in the manual. This chart is purely a reference to illustrate how responsibility for standards can be divided across the cancer

committee to promote better engagement and to ensure members are taking responsibility for standards specific to their qualifications.

The chart on this page details cancer committee roles as defined in Standard 1.2. The appointed coordinators are responsible for compliance

with the designated standards. The chart on Page 2 provides suggestion for cancer committee members who may be appropriate champions for the

remaining standards that do not require a specific member coordinate the standard.

Cancer Committee Role ER/Standard

Responsibility Cancer Committee Meeting(s) which require reports

(1Q = First Quarter Meeting, 2Q = Second Quarter Meeting, etc.)

Palliative Care Professional 2.4 At least one meeting each calendar year

Genetics Professional 2.3 At least one meeting each calendar year

Cancer Conference Coordinator ER 3, 1.7 1Q (annual review of Eligibility Requirement (ER) policy and procedure (P&P))

4Q (annual report on cancer conference monitoring)

Quality Improvement Coordinator 4.7, 4.8

1Q (lead cancer committee discussion to identify two problems to study for Std 4.7)

At least one more meeting in the same calendar year to report results and report on two

implemented quality improvements

Cancer Registry Quality Coordinator ER 5, 1.6 1Q (annual review of ER P&P)

4Q (annual report on quality review results)

Community Outreach Coordinator 4.1, 4.2, 1.8

1Q (identify cancer prevention and screening needs of the community/local population)

4Q (Presentation of Community Outreach Report which includes all elements listed in

Standard, including monitoring of effectiveness of Standard 4.1 and 4.2 programs)

Clinical Research Coordinator ER 9, 1.9 1Q (annual review of ER P&P)

4Q (Clinical Research Accrual Report)

Psychosocial Services Coordinator ER 10, 3.2 1Q (annual review of ER P&P, establish psychosocial process)

4Q (evaluate process and provide Annual Psychosocial Services Summary)

Oncology Nurse ER 4, 2.2

1Q (annual review of ER P&P)

At least one more meeting in the same calendar year to report outcomes of the annual

nursing competency evaluations

Cancer Liaison Physician 4.3, 4.4, 4.5, 5.2

At least four separate meetings per calendar year (recommend reporting on other NCDB

tools in addition to those required under 4.4 and 4.5).

5.2 requires RQRS reports semi-annually.

DIVIDE AND CONQUER Suggestions for Commission on Cancer Standards Champions

Standards/ER Potential Responsible Person Meetings which require reports

Remaining

ERs

Cancer Program Administrator (CPA), Cancer Committee

Chair (CCC), Any required or non-required committee

member 1Q (annual review of ER P&P)

1.1 CCC None, but responsible for SAR

1.2 CCC 1Q (appoint required members and alternates)

1.3 CCC Documentation of cancer committee attendance at all meetings

1.4 CCC 1Q (establish meeting schedule)

1.5 CPA, CCC, Any required or non-required committee member 1Q (establish one clinical goal and one programmatic goal) 2Q/3Q (first review of goal process) 4Q (second review of goal process)

1.10 CPA, CCC, Any required specialty physician 1Q/2Q (develop educational activity)

1.11 CTR, Cancer Registry Quality Coordinator None, but responsible for SAR

1.12 Marketing + coordinator related to standard used in public

reporting 4Q

2.1 Pathologist or any physician on the cancer committee At least one meeting each year to report audit results

3.1 Social Worker, Oncology Nurse, Any required or non-

required committee member with appropriate background 1Q (review CNA & choose barrier to address) 4Q (evaluate process)

3.3 Oncology Nurse, Physician champion, Any required or non-

required committee member with appropriate background 1Q (discuss current SCP processes) 4Q (review process and standard compliance)

4.6 CLP, CCC, Any required or non-required physician 1Q/2Q (decide cancer site to analyze) One additional meeting in the same calendar year to report results of the in-

depth analysis and recommendations for improvements, if needed

5.1 CTR, Cancer Registrar Quality Coordinator None, but responsible for SAR

5.3 CTR, Cancer Registrar Quality Coordinator None, but responsible for SAR and follow-up documentation at survey

5.4 CTR, Cancer Registrar Quality Coordinator None, but responsible for SAR and follow-up documentation at survey

5.5 CTR, Cancer Registrar Quality Coordinator None, but responsible for data submission

5.6 CTR, Cancer Registrar Quality Coordinator None, but responsible for data submission/accuracy of data

5.7 Varies Varies