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CAP Home > CAP Accreditation and Laboratory Improvement > Completeness of Cancer Reporting

  QM2 - Completeness of Cancer Reporting

 

Posted January 16, 2012

In 2004, the American College of Surgeons Commission on Cancer introduced Standard 4.6 (now Standard 2.1) for accredited Cancer Centers pertaining to pathology reports. The Commission required that at least 90% of cancer resection reports contain all of the required data elements defined by the CAP Cancer Protocols. The CAP Laboratory Accreditation Program contains a similar requirement (ANP.12350). The Joint Commission standards for medical staff MS.4.15 and MS.4.40 stipulate that medical staff members undergo Ongoing Professional Practice Evaluation (OPPE) more often than every year, and completeness of cancer reporting has been suggested as one measure suitable for OPPE. Finally, the CMS pay-for-performance standards for pathologists provided incentives for the inclusion of specific elements in colon, breast, and prostate cancer reports (H.R. 6111). This ongoing quality performance measure can be used to assess whether departments are in compliance with standards related to cancer reporting. The data may also be subcategorized by individual pathologist for use in ongoing professional practice evaluations.

Objective

Determine the adequacy of cancer reporting.

Data Collection

To achieve the Commission on Cancer Center designation, the lesser of 80 cases or 10% of cancer reports must be reviewed each quarter for adequacy. For other laboratories, a minimum of 30 cases per quarter is required for evaluation. Institutions may optionally collect data for individual pathologists to be used for ongoing professional practice evaluations. Reports will be evaluated for the presence of all CAP-required data elements, as specified in the CAP Cancer Checklists, and the use of synoptic format.

Performance indicators

  • Primary:
    • Percent of complete reports (all required data elements present)
    • Percent of reports using a synoptic format
  • Secondary: (optional)
    • Pathologist-detail report: summarizes each pathologist performance with respect to completeness anduse of synoptic format.
 

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