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Oncology Quality Studies: Creating a Team of Subject Matter Experts

There is a Japanese proverb that says, “Vision without action is a daydream. Action without vision is a nightmare.” When cancer programs start establishing the quality initiative activities each year, they should set aside time to plan and explore proposed topics before launching into analysis or implementing solutions. Failure to take plan or methodically conduct a study is an inefficient use of resources and places compliance with the standards at risk. Studies managed in this manner are a nightmare to conduct and generally decrease its value and benefit to the cancer program and patients.   

In 2020 the Commission on Cancer (CoC) introduced Standard 7.3 Quality Improvement Initiative. Fairly significant changes were made to the requirements including the appointment of a quality initiative coordinator, study guidance by the Cancer Liaison Physician (CLP), an expected length of time for study activities and other required elements. There are eight core steps in a quality study process that will ensure compliance with the 2020 program standards and add value to the bottom line. These steps are as follows:

  1. Appoint a Quality Initiative Coordinator and study team,
  2. Identify the cancer-related problem,
  3. Define how the study will be conducted (methodology),
  4. Conduct the study according to the methodology,
  5. Prepare the summary analysis,
  6. Benchmark results and develop conclusions,
  7. Design and implement a quality improvement plan,
  8. Develop a long-term plan to monitor effectiveness.


Step One: Appoint a Quality Initiative Coordinator

It is crucial that the Cancer Committee appoints a skilled Quality Initiative Coordinator to lead the study team. Ideally a member of the facility’s Quality Improvement Department will be assigned to the Cancer Committee and program for the duration of the study. When searching for a Quality Improvement Coordinator, the Cancer Committee should look for an individual who exhibits the following skills and competencies:  

  • Personal energy, enthusiasm, and warmth,
  • Communicates in an open, assured manner,
  • Has proven verbal and written communication skills,
  • Can quickly establish rapport with team members,
  • Encourages team members to participate in discussions and team activities,
  • Establishes goals, a sense of direction, and quality vision with the team,
  • Demonstrates familiarity with relevant quality improvement methodologies,
  • Keeps stakeholders informed regarding the study progress,
  • Proactively seeks feedback from the CLP and other members of the team,
  • Identifies deliverables and sets reasonable schedules and timelines,
  • Helps the team to identify and analyze the problematic issues,
  • Introduces new resources or members to the team as needed to achieve goals,
  • Involves all members of the team in the process of developing the final analysis and benchmarking of results.

Of note, a cancer registrar, regardless of whether they perform case abstracting or not, cannot be appointed to fill the role of the Quality Improvement Coordinator. However, they may serve as a member of the team and contribute to the study activities.    


Cancer Liaison Physician (CLP)

As a required member of the study team, the CLP is responsible for providing clinical expertise, guidance, and oversight in collaboration with the Quality Improvement Coordinator, study team members and Cancer Committee. The CLP helps to identify the subject matter experts (SMEs) for the team. The CLP may also be involved in providing status reports to the Cancer Committee and contributing to the writing and final analysis of study results.  


Appointing Members to the Team

A multi-disciplinary team of SME’s is needed to ensure that the study is completed in a timely manner and that results are relevant to the patient care delivery process, organizational goals, and vision. The Cancer Committee should consider appointing team members from the following specialties where appropriate:

  • Physicians (surgery, medical oncology, radiation oncology, pathology, radiology),
  • Supportive Care (palliative, hospice),
  • Nursing (including nurse navigators),
  • Psychosocial Distress (case management/social work)
  • Rehabilitative Services,
  • Oncology Nutrition Services,
  • Spiritual or Pastoral Care,
  • Financial Services,
  • Scheduling, transportation, or
  • Other allied health professionals as needed.

There are no minimum requirements on how many individuals are on the team. The best team will be large enough to accomplish the multidisciplinary goals and small enough to facilitate completing the study in a timely manner.    

One suggestion is to form a core team of members, or the minimum number of individuals needed to complete the study, followed by ad hoc or general members who participate in a limited capacity relevant to their subject matter expertise.  



In summary, the CoC introduced new cancer program standards in 2020 that changed the format and structure for conduct of quality study activities. Establishing the Quality Improvement Coordinator and team to conduct the study is the first step taken to planning a successful study. It is important to appoint members who are SME’s and committed to the vision and goals the study aims to achieve. The Quality Improvement Coordinator and CLP collaborate to provide leadership and oversight for all study activities and are responsible for providing updates to leadership and the Cancer Committee. While the cancer registrar cannot serve as the Quality Improvement Coordinator, they can and should be a part of the study team involved in the collection, analysis and summary of the data and results.      

This post is the first of several posts dedicated to cancer-related quality improvement initiatives. 

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AHIMA Approved

This program has been approved for continuing education unit(s) (CEUs) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting of Approved CEUs from AHIMA does not constitute endorsement of the program content or its program provider.