Duke University Hospital’s NCI-Designated Comprehensive Cancer Program recently earned a three-year accreditation rating, with commendation, from the Commission on Cancer (CoC).
Established in 1922 by the American College of Surgeons, the CoC is a consortium of professional organizations dedicated to improving survival and quality of life for cancer patients through standard-setting, prevention, research, education, and the monitoring of comprehensive quality care.
“Duke University Hospital’s cancer program, now organized under the auspices of Duke Cancer Institute, has held CoC accreditation since 1939,” said Steve Power, MBA, administrative director of Quality & Outcomes for Duke Cancer Institute (DCI) and a member of the DCI Cancer Committee. “While most of our peer institutions are also CoC-accredited, it’s great to be recognized with commendation. It shows we have investments and strengths in the right places. Our faculty and staff are to be congratulated.”
Every three years, the cancer programs are judged by as many as 34 quality care standards. They must meet or exceed all applicable standards (in Duke’s case, 24 standards) in order to earn voluntary CoC accreditation.
Three-Year Accreditation with Commendation is only awarded to a facility that receives a commendation rating for one or more standards and with no discrepancies.
There are six quality care standards eligible for commendation. Duke earned four — for Clinical Research Accrual, Public Reporting of Outcomes, Oncology Nursing Care, and Data Submission and Accuracy of Data.
“The opportunity to enroll in clinical trials is why patients come to an academic medical center, so we’re living up to our name,” said Power, explaining that enrolling more than 30% of cancer patients in clinical trials was what qualified the DUH cancer program for a commendation in that area.
For the three years surveyed, Duke’s accrual rate in fact ranged between 35 and 54%, he explained.
According to the accreditation report, the inclusion, in three successive Duke Cancer Institute Annual Reports, of the number of patients screened via mammography, Pap smears, colonoscopy and prostate specific antigen (PSA), automatically earned the DUH cancer program a commendation for the outcomes reporting standard.
The Duke University Hospital (DUH) cancer program also qualified for a commendation for the nursing care standard. That's because 25% or more nurses are certified OCNs.
“The number of oncology-certified nurses shows our program’s dedication to this field,” said Power, noting that in Duke’s case more than 35% of nurses were certified OCNs.
Duke Cancer Institute’s Tumor Registry data submissions to the National Cancer Database (NCDB), meanwhile, exceeded the terms and conditions for the NCBD 2016-2018 Calls for Data; earning a commendation for the data standard.
Power credits the leadership of Tumor Registry director Wendy Gregory, BS, RHIA, CTR, for this commendation.
"She and her team worked very hard to achieve this," he said.
Jointly run by the American College of Surgeons and the American Cancer Society, the National Cancer Database is a nationwide oncology outcomes database for the more than 1,500 CoC-accredited cancer programs in the U.S. and Puerto Rico. Registry data from some 70 percent of all newly diagnosed cancer cases — including patient characteristics, cancer staging, tumor histological characteristics, type of first course treatment administered, and outcomes information — are submitted to the NCDB, which now contains approximately 34 million records from hospital cancer registries.
A cancer liaison physician at each CoC-accredited institution monitors and evaluates the cancer program’s performance using NCDB data and reporting tools and conveys his findings quarterly to the DCI Cancer Committee.
The CoC surveyor assigned to evaluate DUH’s cancer program commended the cancer liaison physician, Dan Blazer III, MD, for “a great job mining the NCDB data for academic projects,” as well as for “improving program performance.”
The DUH cancer program also earned CoC praise for meeting all three Continuum of Care Services standards — the patient navigation process (including a demonstrated commitment to address barriers and disparities), psychosocial distress screening, and survivorship care plans.
CoC-accredited cancer programs are required to show evidence of providing disease site-specific survivorship care plans to more than 50% of eligible patients. While many large programs struggle with this requirement, the surveyor described the DUH cancer program as particularly “robust” in this area.
"The surveyor told us that programs our size generally don’t meet the 50%, but that we seemed to have met it easily," recalled Power. "I told him that we worked really hard to achieve this. It wasn’t that easy.”
As part of the triennial accreditation process, the CoC surveyor makes a one-day site visit to Duke Cancer Center and Duke University Hospital. The surveyor attends a tumor board and tours the facilities, among other things.
The latest site-visit, held on March 5, began with the surveyor’s attendance at a hepatobiliary tumor board led by surgical oncologists Blazer and Sabino Zani, Jr., MD.
The surveyor noted that the tumor board, which was discussing many pancreatic and liver cases that day, was “clearly a meeting of highly experienced professionals sharing opinions of the best approach to difficult problems.”
In the accreditation comments he also mentioned Duke Cancer Center’s “spacious and attractive” physical spaces — singling out its elaborate patient resource center, the fireplace, the (Belk) boutique, the quiet space for contemplation, the memorial floor, and the piano playing.
As CoC standards evolve, staying up-to-date and in compliance are important, explained Power. Even better, earning commendations.
“Right now, our committee is learning what adjustments we need to make for the next iteration of standards that have just come out for comment,” said Power.
The next survey date for DUH’s cancer program will take place in February 2022, covering years 2019, 2020 and 2021.