Transcript MOQC Webinar #2 (QOPI Certification Requirements & Timeline)

Getting Ready for QOPI Certification
Part II
February 21,2012
Use Mute Button on Phone
Use Raise Hand function or Write a Question
For Assistance go to MOQC.org or call:
734.763.7398
Today’s Agenda
I.
II.
III.
IV.
V.
Certification Process Overview
Policy & Competency Requirements
Data Submission Tips & Tricks
MOQC Resources
Future Webinar: Site Visit Preparation
QOPI Certification Overview
• Demonstrates highest level of commitment to
quality and safety for oncology practices
• Prepares participants on how to conduct self
assessments of policies, staff competencies &
documentation associated with key processes
in their offices
• Primary focus is on the safe administration of
of chemotherapy and biologics
Drug
Preparation
Drug
Administration
Monitor &
Assessment
Chemotherapy & Biotherapy Administration
Patient Centered Care
Culture of Safety & Quality
Staff Education &
Competencies
Policies &
Guidelines
Chemotherapy
Plan
Eligibility Requirements
• Starts with submitting data for all 5 modules
during one collection round
• Compliance with QOPI chart selection &
sampling methodology
• Achievement of QOPI scores to be
Certification Eligible:
– Overall Quality Score : 72.62% or higher
– Adjuvant Treatment Score : 80% or higher
Certification Process
QOPI Thresholds met
Practice is Eligible
Certification Password Obtained
 Complete Application & Payment based on
practice MD FTE (prior to March 22nd)
 Complete Site Assessment Questionnaire &
Attestation Statement
Submit ASCO Designated Documentation on
5 Safety Standards & 3 Medical Records
II. POLICY & STAFF COMPETENCY
REQUIREMENTS
Staffing Related Policies/ Elements
Required Policy Elements:
Who can perform the task & how are they deemed qualified
 Chemo orders incl. oral are written & signed by L.I.P.
 Chemo drugs preparation by qualified staff
 Administration of chemo is only by qualified MD, PA/NP, RN

How new staff that administer are educated incl competency
(skills) assessment/ verification
Chemotherapy administration competency monitoring schedule

(how & how often- annually recommended)
Chemotherapy Orders, Preparation &
Administration Policy/ Elements
 Required ordering elements (or submit std order form)
 Double check process elements required before preparation
 Double check process elements required before administration
How cumulative doses are captured/ monitored (or submit form/

screenshot)
Intrathecal administration includes special preparation, storage

& delivery requirements
How communication & documentation of toxicity will occur

across sites of care within a practice if applicable
General Practice Policies/ Elements
 Informed Consent process
Standard clinical assessment elements (ie. VS, Wt, Allergies

etc.) (or submit standard form/ screenshot)
 Medication reconciliation process incl. when & how collected
Extravasation management procedure including antidote

order sets & procurement process
 Missed appointment tracking & follow up process
 How patients access providers during & after hours
Emergency preparedness policy incl. plan for life-threatening

emergencies (or checklists)
ASCO.org \ Practice & Guidelines \ Quality Care \ Quality Measurement &
Improvement \ ASCO-ONS Standards for Save Chemotherapy Administration \
Download: Sample Policies for Safe Administration of Chemotherapy
Staff Education Requirements
Testing: Acquiring Knowledge
Competency Assessment:
Demonstrating Proficiency
Required Staff Education & Competencies
• Testing assesses knowledge
• Competency assessment evaluates skills and
performance
• Both are required for staff who administer
chemotherapy with annual review that
includes a competency assessment
• BLS: Minimum requirement for RNs
• Submission of staff records required
III. DATA SUBMISSION TIPS & TRICKS
Certification Standards Overview
• Each standard set up in the same manner:
– Standard Description
– Policy Required (if applicable)
– Acceptable Documentation to submit
– Available References & Resources
• Only send documentation showing evidence
that standard met – no highlighter!!
• De- identified records only- or need to resubmit
• ASCO tells you which 5 modules to submit data
Chemotherapy Planning:
Standards #2&3
#2 Required Documentation Prior to New Order





Pathology Report
Cancer Stage at diagnosis or current status
History & PE ( including Ht, Wt)
Allergies & history of hypersensitivity reactions
Psychosocial assessment (ESAS, Distress Tool)
Chemotherapy Planning (cont.)
#2 Required Documentation Prior to New Order
Chemotherapy Treatment Plan
– Goals of Therapy (curative / palliative)
– Drug, dose & duration
– Acknowledgement of patient understanding of the
information
2 records sent demonstrating compliance
Chemotherapy Planning (cont.)
#3 Informed Consent Documentation Required
Send two recent completed forms or notes with
policy
Oral Chemotherapy Documentation Required
All of the above
Frequency of office visits
Monitoring parameters
Chemotherapy Orders:
Standard 4
Orders Requirements
Order forms list all chemo & dosing parameters
Full generic name used
Abbreviations follow Joint Commission
standards
http://www.jointcommission.org/standards_information/npsgs.aspx
Completed unique order sets for 3 patients
sent (including and anthracycline)
Chemotherapy Orders (cont.)
• Required Elements on a Chemotherapy Order:
– Patient full name & 2nd identifier
– Date Diagnosis
– Regimen Name & Cycle # (Protocol Name /#)
– Allergies, Ht/ Wt ( or other dose calc)
– Dose calculation method (ie. creatinine clearance)
– Route, Rate, Dosage, Length of Infusion, Sequence
– Supportive care treatments
Drug Preparation:
Standards 5 & 6
• Double Check Documented Prior to
Preparation
• Chemotherapy Drugs Must be Labeled
Immediately Upon Preparation
– Standard format included in guideline
– Time of expiration added when not for immediate
use
Drug Preparation:
Standard 7 Intrathecal Administration
•
•
•
•
Prepared only with other intrathecal agents
Uniquely identifiable intrathecal label
Stored in an isolated container/ location
Delivered to patient only with other meds for
CVS administration
• All procedure areas in organization must
follow same policy incl. IR, Procedure Units
Chemotherapy Administration:
Standard 8 Double Check
• In the presence of the patient, verify patient
identification using at least 2 identifiers
• Confirm with patient planned treatment prior
to each cycle
• Double check completed & documented
(required elements listed in standards)
• Checklist, template recommended
*** Competency validated on annual basis
Chemotherapy Administration:
Standard 9 Extravasation Management
• Policies / guideline & order sets align with
current literature ( 2009 ONS Chemotherapy & Biologics
Guidelines And Recommendations For Practice )
• Antidotes & order sets must be accessible on
site or need written procedure on where
patient is sent or how antidote is sent to area
NOTE: Totect treatment for anthracycline and
hyaluronidase for plant alkaloids are current
recommendations
Monitoring & Assessment:
Standard 10: Emergency Preparedness
• Emergency protocols/ checklists are
maintained for life–threatening emergencies
– Who needs contacted to get help / responds
– How are they contacted (i.e. page/phone number)
– Assigned role of staff during the emergency
– Procedures implemented when further care is
required (including transfers)
Monitoring & Assessment:
Standard 11: Clinical Assessment
On each clinical visit including infusion the
following is assessed / verified and documented:
– Clinical/ performance status
– VS, Wt,
– Allergies, previous reactions & treatment- related
toxicities
– Psychological concerns (with plan if indicated)
Screenshot or form can be submitted or policy
Monitoring & Assessment:
Standard 12: Medication Reconciliation
On each clinical visit including infusion review of
the following will occur:
– Current medications
– OTC meds
– Complementary & alternative treatments
Changes are documented in the medical record
Monitoring & Assessment:
Standard 13: Referral Resources
• Required to have listing of psychosocial &
supportive care resources
• Resources include list of websites, booklets,
community programs etc
Monitoring & Assessment:
Standard 14/15: Access & Communication
#14 Missed Appointments
– Need missed appointment policy &/or tracking
process which includes patient follow up (i.e. call,
email to patient)
#15 Provider Communication
– Process to provide 24/7 triage (i.e. on call
process) for care of toxicities
– Ability to communicate toxicities across sites
– Tracking of Safe Hand-Offs- HOLD
Monitoring & Assessment:
Standard 16/17:Toxicity Monitoring
#16 Toxicities Assessment Documentation is
Available for Planning Subsequent Cycles
– Flow sheets, provider notes of review
#17 Cumulative Doses are Tracked When
Indicated
– i.e. Documentation of doxorubicin cumulative
dosing for patient receiving AC protocol; EMR
screenshot of tracking; flow sheet
Drug
Preparation
Drug
Administration
Monitor &
Assessment
Chemotherapy & Biotherapy Administration
Patient Centered Care
Culture of Safety & Quality
Staff Education &
Competencies
Policies &
Guidelines
Chemotherapy
Plan
Next Steps
• Assemble your team including physician
champion
• Conduct a self assessment/ gap analysis
(MOQC tool)
• Identify opportunities for improvement
• Use ASCO & ONS resources
• Work with MOQC colleagues to identify best
practices
• Conduct Mock Survey
All QI information can be accessed via the MOQC.org website starting March, 2012.
Please email [email protected] or [email protected] for log-in information.
MOQC Lunch & Learn Series
• To better meet your needs, we would like your
feedback and input. Please complete
Evaluation Survey at:
https://umichumhs.qualtrics.com/SE/?SID=SV_ehqdiP2GOhwUxwg
• Future Webinars
– Certification Part # 3 Site Visit Preparation
– Improving Cancer Pain Management