SoYoure Going To Be Surveyed

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SoYoure Going To Be Surveyed???? TxTra
Annual Educational Conference Austin, Texas
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On your mark.get set.GO!! Preparing for the
Survey.
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Time for Survey CoC assigns facilities to
surveyors at the beginning of every
year. Notifications e-mailed in July prior to
the year of survey. Extensions must be in
writing 45 days of survey notification. Update
all contact information. CoC will notify each
facility with surveyors information.
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The surveyor will contact the registry to
schedule a date for the survey.
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One Year Before Survey is Due Review and
document all ACoS Standards. Make sure you
have the current standards. Meet with or e-mail
all key players of the committee prior to the
survey. Form a Survey task force to meet
regularly.
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Begin Strategy Review at-least 2 standards per
month. Review By-laws. Review and update
Policy and Procedure Manual. Begin completing
draft of survey application. Download the SAR.
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When each facility begins working on the SAR make
it as easy as possible!! Distribute appropriate
information to individuals on the committee to
complete. Example Standard 4.2 Clinical
Management- Based on the category, an inpatient
medical oncology unit or a functional equivalent
exists to provide specialized care to patients.
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Give any information pertaining to standard 4.2
to the person on the committee, the nurse manager
or person representing the oncology unit of the
hospital. Keep it simple. Designate jobs to
members on the committee. Make sure all
committee members know the standards and what
each standard entails.
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Registry Concerns Review all case finding
sources. Abstracting within 6 months of
diagnosis. Follow-up rate for all patients at
90. Follow-up rate for living patients at
80. All information and concerns should be and
MUST be communicated at each task force and
committee meeting.
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Documentation Documentation is vital! The
committee meeting minutes is proof of compliance.
Proper documentation is something that can
always be worked on. If its not documented it
DID NOT happen!
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Cancer Committee/Conferences Attendance at
cancer committee meeting. Cancer committee
minutes. Cancer conference Attendance Prospe
ctive presentation, new requirements.
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Registry Manuals and Logs Policy and Procedure
Manual should be reviewed and updated yearly.
This serves as a record of changes in the
registry. The Request Log should have all
documentation of request for data. This includes
request from hospital Administration, clinicians,
other facility departments, Quality Improvement
studies. This proves the facility is using the
Cancer Registry data.
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Quality Assurance Log Log of all QA activities
from each monthly physician review. Example
2006 Physician Quality Control Review Registry
Abstract Against Medical Record, CAP Protocols,
and AJCC Staging Results.
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Registers Accession register for the last
complete year. Suspense list.
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Records for Review The surveyor will review each
of these items in the medical record. Pathology
reports. Operative reports. Staging
sheet. Discharge planning. You will need to make
sure all appropriate documentation is available
for the review. Mark each of the items to make it
easier for the surveyor.
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Registrars Do not scrimp on registry staff or
the whole cancer program will suffer. If the
registry is not abstracting in a timely manner
and the needs are not respected, the abstracting
will not be completed and meet reporting
requirements. Registrars are responsible for the
quality of the data, abstracting, and data
submissions. 3 of 5 most frequent deficiencies
in 2005 were the responsibility of the registrar.
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Survey Ratings Commendation Compliance Non-C
ompliance
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After you feel everything is in order and all
documentation is as complete as can be. Set a
date for everyone on the task force such as
hospital administration, appropriate physicians,
and management can meet to review the SAR. This
way everyone is on the same page and all
information documented in the SAR is correct.
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Almost to the finish line!!!!
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Dont sweat the small stuff.! Make sure
catering has been ordered. Make sure room set-up
has been arranged. Make sure any required items
have been reserved, such as computer, large
screen, projector, ect Review all information
requested by the surveyor to make sure nothing
has been left off the list! Remember to Breathe!
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Make sure your agenda for the survey has been
prepared! Make sure the agenda includes all
required standards. Make sure all items requested
by the surveyor has been sent 14 days before the
survey! Make sure the information sent includes
directions to the facility, access code for
parking, agenda, ect!
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The day of Survey Stay calm, breathe, relax!
Dont Panic!! Observe. Ask for help if
needed. Surveyor may ask for reports. Be
prepared for anything unexpected to happen!!
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Tips Strong administrative support is
essential! Physician attendance and
participation is essential! Survey Savvy. Have
a check list with assignment to members of the
Cancer Committee.
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