Monitoring Compliance for CoC Standard 5.8 Pulmonary Resection

Michele Webb, CTR Oncology Leave a Comment

Monitoring Compliance for CoC Standard 5.8 Pulmonary Resection

In 2020 the CoC announced new operative standards and quality measures for breast, melanoma, colon, rectum, and lung primary sites. Two of the standards went into effect on January 1, 2021, including Standard 5.7 Total Mesorectal Excision (Rectum) and Standard 5.8 Pulmonary Resection (Lung). Compliance with each standard is based on documentation in the pathology reports and requires communication directly from the surgeon to the pathologist to demonstrate compliance.

The scope of Standard 5.8 applies to all primary surgical resections, regardless of operative approach, performed with curative intent for non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC) or carcinoid tumors of the lung. The threshold or levels for compliance begin at 70% in the first year of implementation increasing to 80% in the second and subsequent years as shown below.

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The operative and surgical pathology reports associated with any curative intent pulmonary resection for primary lung cancers must include the oncologic status of lymph nodes from at least one hilar station (Station 10 left or right) and at least three distinct mediastinal stations (Stations 2 (left/right), 3A, 3P, or 4 (left/right). See also SEER Training for Lung Cancer, Regional Lymph Node anatomy.

In the pathology report, the required data elements must be documented in synoptic format as defined by the College of American Pathologists (CAP). See also CAP Cancer Protocol templates for the current Lung Resection version.

Monitoring compliance with the standard is at the discretion of the Cancer Committee and while reporting to the Committee is also not required it is advisable. The Cancer Registrar’s role in auditing adherence is limited to extracting data from the Registry data management system, verifying the required documentation in the EMR, and communicating results to the Cancer Committee chair. Physician leaders in the cancer program will need support from the facility’s medical and administrative leadership to communicate, monitor, ensure compliance or implement any necessary corrective action.

The Cancer Registrar is an appropriate member of the team to conduct routine audits on compliance with the cancer program standards. The ACoS has published Case Identification Guidelines and Flowchart to Assess Compliance documents to help with the audit. Registrars should be familiar with these resources and the tools and reference documents published by the American College Surgeons, Cancer Surgery Standards Program (CSSP). These resources establish a formal plan to audit and report results. Cancer Registrars should consider including a description of the CSSP audit process in the Cancer Registry policy and procedure manual.

The audit is based on review of the source documents and cancer registry data as shown below and easily inserted into a spreadsheet or table for results reporting. Review must include the data elements as shown below.

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While auditing is not required, it is advisable. No one wants to wait until the triennial site visit to determine they are, or are not, compliant with the standard. The Cancer Registrar should work with the Cancer Committee Chair and surgery representative to establish a reporting timeline and any additional data elements needed for review. It is reasonable to establish quarterly reviews to reduce the time and burden on the Registrar. Quarterly reports may be provided to the Committee Chair in advance of each meeting, leaving an appropriate amount of time to communicate with the surgeons, pathologists or leadership teams should corrective action be needed.

Registrars should anticipate having questions that need clarification while conducting the review. There is a high degree of variability in how surgical procedures are performed and documented in operative reports which may not always correlate to how the standards are written. Refer to the CAnswer Forum for CSSP recommendations on resolving discrepancies or how to assess the validity of the documentation at your facility.

The Cancer Registrar should be prepared to create and propose an audit results report to the Cancer Committee Chair and leadership team. These individuals may have feedback or data elements they want to include. The Registrar should be careful to not reveal results by individual name unless requested to do so by the Chair. In most cases, a summary table with the total cases reviewed, data elements, and percent compliance will be sufficient. Do not underestimate the power of using both a data table and a graphical image to communicate these results.

It is no surprise that change can be difficult for most people and surgeons are no exception. From their early years in residency to the current time they have dictated operative reports using their own unique style and flair. It is important that the Registrar collaborates with the Cancer Committee Chair and surgery representative to formally communicate with the facility’s surgical providers regarding the documentation requirements. In addition to memos or letters, visual abstracts, research and peer review articles or graphical tools and resources may help them adopt new habits and be supportive of the cancer program needs. The goal of this standard is to ensure complete clinical and pathologic staging of disease, enhance timely coordination of care and achieve better outcomes and survival.

In summary, periodic auditing for compliance is time well spent and ensures that standard compliance is adhered to throughout the calendar year. The Cancer Registrar’s role in monitoring compliance should be limited to pulling data from the Registry database and verifying or confirming documentation in the EMR. Use of a simple data collection form that correlates to the selection criteria and scope of the standard can be prepared and shared with the Cancer Committee and the facility’s administrative leadership team who determines the best methods for communicating with the surgeons and pathologists.

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