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nda rd 2 .5: Q ualit y Imp rove me nt P lan S am ple ect: ittee Quality I mprovem ent Plan tment: er Pr ogra m #: Date: ive D ate: Management and Im provement Plan is to ensure that the Tumor Registry of XYZ Region al Medical Center dem onstrates a consistent endeav or to deliver optim al care in an environment of minima l risk. The Quality Management and Im provement Plan allows for a sy stematic, coordinated, and continu ous approach to im proving perform ance by focusing on the processes and mechanism s that address these v alues. icy: rdinated and collaborativ e effort, the approach to improving performance inv olves multiple departm ents and disciplines in estab lishing the plans, p rocesses, and m echanisms that com prise performance im provement activities. This program , established by XY Z Regiona l, with support and approval from the Medical Staff, has the responsibility for m onitoring every aspect of patient care, reatm ent of m aligna nt disea ses, in order t o identi fy and resolv e any break downs that m ay res ult in ement Priorities: nostic or therapeutic procedu res are performed fo r clinically valid re asons. 2. Assure that health c are services are accessib le and available to all segments of the population who ed of them. ard the goal of inc reased desirable outcom es. 4. Assure appropriate, accurate, and com 5. Focus on prov iding appropriate and timely con sultation, diagnosis, follow-up of findings and tests, and timely referrals to assure continuity of care. 6. Provide for c oncise compilation of information that w ill be of value to o ther organizations, including reference databases. 7. Provide for e stablished criteria that allow for ities wi ll be ba sed upo n assess ment of oppo rtunitie s for im prove ment, and/or on the n eed to inate undesirable chang e in performance. 8. Assure that effort is m ade to provide care that is sufficient to assure p atient cooperation and satisfaction. ure com pliance with th e requir emen ts of all federal , state, and acc rediting agenc ies in re gard t o ment and perform ance improv ement activities. will be responsible for coo rdinating the Quality Management and Im provement Plan, and will assem ble criteria, standards, professio nal literature, statistics from reference data bank s, and whatever inform ation is necessary to enable the Com mittee to eva luate their performance , to plan improvem ents in patient care, and to implem ent such improv ements. The Tum or Registrar will use the ng so urces to identif y opp ortuniti es for im prove ment: arativ e surv ival a nd outc ome d ata al, regional, or n ational importance nt/fa mily sati sfact ion sur veys ted results found during routine quality m onitoring by the various departmen ts of the hospital s from established treatment guide lines rman of the C omm ittee wi ll be res ponsibl e for: – Dir ecting the ev aluation of the i nform ation by the com mittee mem bers g guidelines fo r prioritizing im provement opportunities in accordance to their impact on mprov ing pa tient ca re – Fin al selec tion of the focu s of stu dies of quality f the Plan ittee will perform an annual evaluation of the Quality Manag ement and I mprovem ent ies of quality were appropriate to our specific site and practice patterns onitoring were app ropriate to identify the high risk, h igh volum e, and pro blem prone a reas of patient care s for providing information to the commu nity regarding issues of av ailabili ty of c are, an d acces s to car e increase in desirable pat,en t outcomes, and effectiveness of the roles of com mittee mem bers to direct the quality managem ent and improv ement of the med ical center nda rd 2 .5: Q ualit y Imp rove me nt G oals Sam ple Sta nda rd 8 .1: Q ualit y Imp rove me nt S am ple Oncology Serv ices Quali ty I mprovement Plan 2006 ission State men t: t ABC Regional Cancer Center is commi tted t o providi ng a full range of s for the preve ntion , diagn osis, tre atmen t and s upp ort for th e can cer pa tients an d their f amilies in munity. With ou r experienc ed physicians a nd staff, the O ncology P rogram pro vides a framew ork e improv ements i n the qual ity of care a nd servi ces by e nsuring t hat the most adva nced trea tment options are avai lable t o our pati ents and by assis ting t hem and thei r fami lies in coping with t he physi cal tional impact of ca ncer. e of Canc er Pro gra m: ave av ailable a full ran ge of service s, a fun ctionin g can cer co mmittee , to pu blish a n ann ual rep ort, conduct cance r confer ences, mai ntain a Cancer Regist ry, coordinat e programs and servi ces wit h relev ant communi ty a gencies, and to promot e profess ional educ ation f or members of the cancer program t eam. Responsibil iti es: ancer C ommittee is a multidisciplina ry committee comp osed of b oard certified ph ysicians, membe rs nistr ation, nursing, social servi ces, ra diology , quali ty a ssurance, health promoti ons and the cer r egis try. op and evalua te annual goals and obj ectiv es for t he cancer pr ogram 2. To organiz e, publi cize, c onduct, and e valuat e regular educati onal and consul tati ve cancer conferences that are mult idisc ipli nary, hospit al-wi de, and pat ient- orient ed make certain that co nsulta tive servic es from all majo r discip lines ar e availa ble to a ll patien ts 4. To plan a nd co ndu ct the re quire d nu mber of stud ies of q uality an nually, o ne to in clude surviva l data and, if a vailable , comp arison data 5. To mon itor and evalua te patie nt care , either d irectly or b y interac tion w ith and review of aud it data her commit tees 6. To superv ise t he cancer r egist ry ( data sy stem) for qual ity control , abst racti ng, sta ging, and f ollow- up 7. To make cert ain that a support ive car e sys tem is avail able for all pa tient s with c ancer, t heir f amili es ensu re that p hysician s and patien ts have acce ss to info rmatio n on clinica l trials Chair man: ves as t he medical direct or for t he cancer pr ogram by c oordinat ing acti viti es and providi ng guidance and ev aluati on of all program act ivit ies t hrough the Cancer Committe e. Perfor ms eview for accurate and consistent phys ician staging and directs the cancer registry activit ies. nitors a nd p articipa tes in the develo pmen t of the a nnu al repo rt. Sup ports c ance r prog ram me mber s to ual duties and objectives in Cancer Li aison Physi cian: ison Physi cian ser ves on t he Cancer Committ ee provi ding guidance and evalua tion of ram ac tivities. E nsure s that re gistry da ta, inclu ding studie s and nation al statistic s are re porte d to Can cer C omm ittee. A ppro ves reg istry data fo r the Fac ility Informa tion P rofile S ystem (FIP S). A ssists s. Coord inates activities with the hos pital and the loca l ACS control staff. Roles/Responsibi lit ies: i-di scipl inary team consi sts of hospit al assoc iates that a re members of the Cancer Committe e. This team : erform s clinica l mana geme nt for th e pro gram by ensu ring a ppro priate p olicies and p roced ures a re in thin eac h department of the onc ology s ervic e line 2. Impl ements qual ity improve ment act ivit ies wit hin each depar tment 3. Focus es on the pr ovisi on of support ive se rvice s for pat ients and thei r fami lies 4. Assist s and works i n public e ducation a ctiv iti es and scr eenings and coo rdinates profe ssional develo pment for d epartmenta l staff ves: e are : Op erat ion s/Fin anc ial, C linic al/Q uali ty, Se rvice /Sa tisfa ctio n an d Sa Program ovisi on of safe and quali ty onc ology pa tient care by providi ng appropri ate ser vices and staf f in acc ordance wit h our organi zationa l quali ty i mprovement plan B. Achieve accr editat ion wit h American Coll ege of Surgeons Approvals Progr am C. Ensure the timel y publi cation of the 2003 Cancer Progr am Annual Report, util izing a time l ine. ment qual ity improve ment ini tiat ives on any sugges ted topi c that demonstra tes t he need for improv ement C. Establi sh improv ement pri orit ies for the cancer program: Breas t Hea lth Pain Management ontinue to o ffer commu nity screening for p rostate, skin and breast canc ers I. Educati on ontin ue to h ost the supp ort gro ups s pon sored by the A merica n Ca ncer S the Fr iend for Lif e program evelop an A BC Region al Canc er Center e ducationa l brochure ssist the Am erican Can cer S two CME activi ties for st aff phy sici ans based on dat a generat ed from, but not l imit ed , r egi st ry dat a and phy si cia n re vi ews h and Pain Management jectives for 20 02 w ere me t. nt Priorit ies: ement pri orit ies for iorities fo r 200 3 du e to fur ther d evelo pmen ts in bo th Br east H ealth a nd P ain M anag emen t. ard 8 .1: Qu ality Impro veme nt Plan Sam ple L CENTER CE R P RO GR AM Q UALIT Y M ANAGE M EN T PL AN ity Man agem ent Plan of the C ancer P rogram is an o rganiz ation- wide, m ultidisc iplinary effort various departm ents and disciplines. ives o f the ca ncer pro gram are in a ccordan ce with the m ission o f PDQ Medical Center to quality, cost- effective care to prom ote the health and well- being of those liv ing in our commun ity. These objectives includ e promotion of cancer prevention an d screening for early provision for up- to-date diag nostic, treatment an d support services, and the evaluation of the effectiveness of v arious treatments and monitoring clinical outcomes inclu ding site-s pecific survival signme nt of R espon sibility al indiv iduals a nd/or g roups a re assig ned v arious r esponsi bilities to effec tively mana ge the quality ivit ies of th e can cer progr am. ed as a multi discipli nary c omm ittee of the Medi cal Staf f with e x-of ficio s fro m admin ist rat ion a nd ho spi tal depa rtme nts and s ervi ces i nvol ved in the C ance r Pro gram. mittee are outlined in the Medical-Den tal Staff Bylaws. ommittee ide s medi cal lead ers hip f or th e Can cer Progr am: oderator for the m ultidisciplinary cancer con ferences –Recomm ends sites to be studied annually based on volume of cases, previous recommen dations for opportunities for imp rovement es as ph ysicia n adv isor to the can cer reg istry edical staff participation of appro priate disciplines to participate in conferences and iaison e memb er of the Cancer Com mittee and suppo rts the Cancer Program by participating in the review an d evaluation of the annual report, acts as a liaison to the Commis sion on Cancer, and participates in the surv ey process. all cancer cases in accordan ce with the data standard s of the Com mission on Can cer. Responsibilities also include providing aggreg ate data for the annual rep ort and studies of quality , and also prov ides support for the m ultidisciplinary cancer con ferences. s the C ancer P rogram by re viewi ng ag greg ate data all quality studies. D ata is then comp iled and presented in an appropriate display format (i.e. g raphs, tables) to facilitate study evaluation by the Cancer Com mittee. Other du ties may include participating in ittee an d/or a Me dical St aff Dep artme nt. Other in dividu als and/ or gro ups m ay be identifi ed and assign ed resp onsibili ty as a ppropri ate to ici pat e in q ual ity i mprove ment a cti viti es of the C ance r Pro gram. ement Process er Program are continuously ev aluated for opportunities for im provement. Once ent opportunity is id entified, the improv ement process is carried out as outlined in th e Organization–w ide Performance I mprovem ent Plan. nd ard 2.5: Qu ality Im pro vem en t Sa m ple ity Managemen t Plan he chanism fo r the continuo us, prospe ctive current performa nce leve ls, a ssess t he need for i nterve ntions that ar e aimed at reducing or elimi nating opportunities for r efining existi ng processes. ves: cation, measurement and evaluation ofthe appropriat eness, timeli ness, efficiency and effectiveness of pati ent care, treat ment and outcomes. 2. To ensure that patients are r espected and care/treatment i s based on individual needs. tify opportunities for con tinuous imp rovement in p atient care and to ensure that ac tions are emented t o improve care. 4. To ensure c oordinat ion and communi cation of qualit y impr ovement ac tivi ties with depar tments that ients. 5. To ensure a continuing level of professional performance by patient care provi ders. ee compli ance with r egulator y bodie s, inc luding t he Commissi on on Cancer (CoC) of t he College o f Surgeo ns (AC oS), Join t Commissio n on A ccreditation of H ealth Care Organiza tions (JCA HO ), American College o f Radiation Onco logy (AC RO ) and other re gulatory Can cer P rogra m Q uality M anag emen t Plan will be c oord inated with th e Co ntinu ous Q uality ement Plan of the Medical Center. The Cancer Program Qualit y Management Pla n will include, but is not li mited t o: (2) evaluation p riorities are defined an d docu mented an nually by the Can cer Com mittee. A um o f one (1) imp rovem ent pr iority mus t includ e impro ving tu mor-sp ecific p atient c are, trea tment, ata from the N ational Can cer Data Base (N CD B) and other pub lished data are survival r ates. t least tw o (2) c ance r patien t enha ncem ents o r impro veme nts are docu mente d in a tw elve-mo nth One or more measur es of qual ity are defi ned for eac h enhancement/ improvem ent. Measur es to each improvement topic are revi ewed and evaluated by the Cancer Committee at least ally. On e (1) o r more meas ures o f qua lity are def ined f or eva luating practitio ners c omp liance with nes. ty I mprovement studi es may i nclude: a. Patie nt sat isfac tion b. Blood and bl ood component admi nistr ation and util izati on c. Perfor mance eval uations based on age appr opriat e care and compe tencie s d. Medical Records documenta tion i ntra- disci plinar y te am on and utilization eval uation including adverse drug reactions f . Surgery case ew g. Risk managem ent act ivit ies h. Util izati on management i. Morbidi ty a nd mortal ity revi ew (Cancer Confere nce) I team res ults as a ppro priate ty and Responsibi lit ies be a mult idisc ipli nary com mitt ee compris ed of, but not li mited t o, rese ntat ives from surg ery, m edic al on colo gy, ra diat ion onc olo gy, d iagn ostic rad iolo gy, p atho log y, trat ion, nur sing, s ocial s ervic es, cancer regist ry, and quali ty a ssurance. The Committee will at lea st quart erly . Additi The Cancer Committ ee will be responsi ble for establ ishing the quali ty i mprovement priori ties of the cancer progr am. The Committ ee shall define qua lit y measur es and guidel ines base d on current national standar ds as well as publi shed li terat ure for the tr eatment of cancer . The Committ ee will monitor liance with tre atmen t guide lines an d rep ort find ings a nd re comm ende d actio ns to th e Qu ality ement Commit tee of t he Medical Cente r. At l east t wo studies of quali ty wi ll be de fined by the Committee each yea r. The Commit tee wil l annuall y ass i-di scipl inary cancer commi ttee i s responsi ble for both the governance and operati ons of the Cancer Program. 2. The Cancer Commit tee is accountabl e for t he qualit y of pr ograms and se rvice s for ca ncer pati ent care . The Cancer Commit tee is responsi ble for the int egrit y, i ntegrat ion, dev elopment, mainte nance, and monit oring of the Cancer pr ogram int erdisc ipli nary qual ity management pl an. The Cancer Commit tee compli es with the Medical Center' s conti nuous quali ty i mprovement plan. edical Direc tor, the Prog ram Ma nager of the Onco logy Prog ram, and ad ministrative ves provide consistent and ongoing leadership in t he Cancer Prog ram to ensure the highest ty t eaching, r esearch, and cli nical c are for the Cancer Progr am. Reports are prov ided to t he Cancer e Ca ncer C omm ittee C hairp erson and O ncolo gy Pro gram Man ager f acilitate , enab le and coor dinate ogram acti viti es with alli ed healt h care prof essional s, depart ment dir ectors and hospit al ion. Reports are submitted to t he Cancer Co tee must be a sta nding commit tee of t he medical staff . The Cancer Commit tee membershi p will include multi disci plinar y phy sici an members f rom diagnos tic and therapeut ic speci alti es ied health professionals i nvolved in the care of cancer pati ents. d cancer car e commit tee res ponsibil iti es and members hip composi tion ar e defined in sed Editi on. ensure t he commit tee' s invol vement i n defini ng, evaluat ing, and moni tori ng qualit y management activ iti es. The Chair person wil l be res ponsible for iviti es and findings. ison Physic ian Am erican Colle ge of Surg eons , Com missio n on Can cer w ill hat the qualit y ass urance act ivit ies of the cancer ncer. be responsi ble for documenti ng all qua lit y management activ iti es of cance r committ ee. The Regist rar wil l perf orm studi es of qual ity designed by the ACoS Commission on Cancer roval and gu idance of the Canc er Com mittee. The su mmarized re sults of national ca re evaluations w ill be reported to the C ancer C ommittee by the C ancer R egistrar. e Ca ncer Co mmitt ee w ill: aniza tion an d Fu nction s Ma nua l for the inform ation and line ation of duties and responsi bili ties for progr ammatic leaders hip for the cancer program. nnu ally defin e key q uality pro cesse s for imp rovem ent in c once rt with th e med ical ce nter's Q uality Improve ment D epartm ent. sure th at all qu ality impro veme nts ac tivities are docu mente d and repo rted to th e Qu ality center on an at least quart erly basis . rdinate edu cational prog rams based on data an alysis (i.e., two cancer pa tient enhanc ements). ty Monitor s of the Cancer Committ ee ure timely d iagnosis, to p romote appro priate dia gnostic p roced ures an d to priate referrals for treatment of cancers. w cancer case present ing to GHI Cancer Center wil l be dis cussed at the cancer conference . Each case wil l be eval uated for appropri ate dia gnosis, work-up, and trea tment. If t here is a questi on in the management of a case, a peer re view for m will be generat ed which outl ines t he concerns a nd recommendat ions of t he cancer conf erence member s. The peer revie w form is then for warded to t he Quality Improv ement Depart ment for action by the appropri ate depar tment. The outcome of e ach acti on is repor ted back t o the commi ttee. In accordance with guidel ines est ablished by t he College of American Pathologist s (CAP); and to assure c ogic findi ngs for "Breast " and "Prost ate" ca ncer ar e bei ng revi ewed and ed. report s are r eviewed f Department of Pathology in accor dance with CAP guideli nes; whic h lis ts cri teri a that should be documented wit hin the pa thology report . These fi ndings are summari zed quarte rly and forwarde d to the Department of Pathology for cor recti ve acti on, if requir ed In accordance with guidel ines est ablished by t he College of American Pathologist s (CAP); and to assure c ogic findi ngs for "Breast " and "Prost ate" ca ncer ar e bei ng revi ewed and ed. report s are r eviewed f Department of Pathology in accor dance with CAP guideli nes; whic h lis ts cri teri a that should be documented wit hin the pa thology report . These fi ndings are summari zed quarte rly and forwarde d to the Department of Pathology for cor recti ve acti on, if requir ed nuousl y str ive f or earl y diagno sis , and i mproved c ancer c are and ival. improve ment st udies wil l conti nue to be per formed. Site- specif ic st udies ar e request ed to suppor t our t care or to identify problem areas that may nee d to be enh anced. T he results of these studies are ed among commit tee member s, and re commendati ons are made f or furt her diss eminati on of resul ts or actions to be t aken. pro ve th e con tinuu m of care for c anc er pa tients wh ich sh ould ultima tely impr ove p atien t surv ival. Can ce r C omm it te e h as ag re ed to fo ll ow t he Nat io na l C omp re he ns iv e Ca nc er ice Guidel ines, for the management of cancer pat ient t hat have be en diagnosed a nd/or treat ment at GHI Cancer Center. Quality measures will be defined for eva luati ng practi tioner 's complia nce guidelines. To measure long-te rm survival of patients with malignant t umors who are diagnosed and/or rec eived fir st course of treatment at GHI Cancer Center ee will annually designat e a sit e-speci fic mal ignancy . Cancer Regis try data wil l be util ized to measure t reatment and survi val r ates. Comparison wi ll be ma de to regi onal and/or national publishe d data. se stud ies will b e pub lished in the C ance r Pro gram 's Ann ual R epor t. Finding s from th is repo rt will be us ed to e stablish future goals for pa tient ca re impr ovem ent. nda rd 2 .5: Q ualit y Assur anc e Sa mp le al th Sy st em Qu al it y A ssu ra nce Pl an - Hosp it al Canc er Pro gra ms ves: y ass urance progr am of the Hospital Cancer Program wil l serv e to del ineate the qual ity of atient care nt Management that a ll pat ients have acces s to consul tati ve serv ices i n all di scipl ines where ver poss ible. 2. To assure that pr e-tr eatment work-up and s taging ar e accompli shed in a t imely , cost -eff ectiv e manner andards. re that cancer p atient treatment and ultimate survival reflect a high stan dard of pra ctice and are ate and national outcomes. sfaction ee will make every effort to addres s the needs of the pa tient s to i mprove pat ient comfort. It is believed that patien ts with positive attitudes tow ard their care ha ve outcomes. ee will stri ve to as sure tha t all data col lecte d withi n the Tumor Regis try is of the highest qualit y achi evable i n order t o provide a meaningf ul databa se. This database is t he essent ial care reviews. ocial Services ee will evaluat e and access the tot al care of the c ancer pat ient, includi ng the bilitative services and soc ial support ems will be evalua ted on a r egular bas is t o assure t hat res ources ar e appropri ate. er Com mittee shall re gularl y rev iew and evalu ate the needs o f the pr ofessio nal staf f. Educati onal top ics shal l be coo rdinated with th e findin gs of the form al eva luation s, attem pting to educational efforts. All edu cational offerings shall b e multidisciplinary and cover the entirescope of cancer care. d comm unity education plays an importan t role in the prevention and treatmen t of cancer. E very will be made to def ine the needs of t he communit y and foc us on prevent ion, sc reening, and ion activit ies. ee shall be responsi ble for ensuring complianc e with t he American Coll ege of Surgeon' s cancer pr ogram st andards. All qualit y ass urance funct ions shal l be coordi nated wit h the tot al hospita l quali ty a ssurance pr ogram. s shall be prob lem-focused , monitoring o nly those areas w hich are kn own o r suspected to have l be pri orit ized accor ding to t heir pot ential impact on patie nt care and outcome, their impact their frequency of occurrence, and thei r impact on cost-eff ectiveness. may include: formal audit with the pre- established crit eria, process revi ews, evaluations. ee shall be responsi ble for the ide ntif icati on and analy sis of problems . Outcome assessme nts and act ion impl ementat ion shal l be ref erred t o the appropr iate m edical staff committ ee or istrative d epartm ent. valuat ion of t he resul ts of c orrect ive act ions shal l be the responsi bili ty of the Cancer Commi ttee. st ann ually, the Can cer C omm ittee sha ll evalua te and acce ss the e ffective ness o f the qu ality program t o assure t hat it will be present ed to th e Cance r Com mittee and sta ff. ital Cancer Pro gram Patient Car e Evaluation Plan sis, evaluation, uestionna + + Problem analysis to identify source of problem + + + Formulate action plans to correct problem + + + Recommend implementation + + + Executive Committee / Administration + + + Approve or modify a ction plan + + + Implement action plan + + + Follow-up through Cancer Committee quality monitoring program y Quali ty Assurance Progr am with the JKL Health Sys tem Quality Assurance Plan, the g oals of the QualityAssurance P lan for the Cancer Reg istry are as follows: ivel y and sy stemat icall y monit or and eval uate the qualit y and appr opriat eness of t he servi ces y the Cance r Registry any ar eas where t he servi ces may be improv ed 3. To demonstr ate eff orts t oward resol ution of identi fied pr oblems sibility : rance team com posed of the Cancer P rogram Manag er, a representative from the Cancer Reg istry Staff, and a physician consultant appointed by the hospital cancer com mittee will reg ularly plan and con duct Quality Assurance reviews. The Cancer Program Man ager has the respon sibility of assuring the plan is implemented and regularly reported to hospital adm inistration and to the Cancer C ommittee if appropriate. is responsible for identify ing all patients diag nosed treated for canc er or Ce ntral Ne rvous Syste m neo plasia a t JKL The records of these patients are abstracted with pertinent data including dem ographics, cancer id entification, treatment, and subsequent follow- up entered into the databa se. nt Asp ects collecte d by t he Canc er Reg istry i s used t o mon itor the car of t he patie nts as compared to national, regional a nd local statistics. The data may also be used to m onitor need for increase in cancer services and administrative d ecisions regarding the increase of serv ices. The data is also used by the medical staff a s a basis for research projects and developmen t of materials for pu blication. will select the indicator to be evaluated and co llect data to assess s. Data collected m ay result from but not be lim ited to are view o f the al recor d, edit check s produ ced by the Ca nsurFac s softw are, dia gnost ic disease listing s from the Med ical Rec ord Dep artme nt, che cklist s, log s, and reports r departments. en pr oblem s are id entified , the Q uality A ssura nce C omm ittee will ta ke ste ps to addr ess the prob lem inc ludin g asse ssmen t of wh o or w hat ne eds to be ch ange d and to ow- ction: r an ap prop riate len gth o f time to a llow fo r chan ge of the pro blem, data tion wi ll agai n be init iated t o assess the eff ectiv eness of t he changes insti tuted. If cha nges are not made the pr oblem wil l be rea ssessed. rvi ew: Flow of Data Diagnostic Disease L isting + + + + of Quality Reporting Administration National Cancer D ata Base y Management Plan Committee Responsibilities: evaluates the annual goals and objectives for the clinical, educational, and atic activities related to can cer •Promotes a c oordinated, multidisc iplinary approach to patient manag ement •Ensures that educational and consultative canc er conferences cover all major sites and related issues es that an activ e suppo rtive c are sy stem is in pla ce for p atients, famil ies, an d staff anagement and improv ement throug that focus on quality , access to care, and outcomes •Promotes clinical research •Supervises the c ancer registry an d ensures accurate and tim ely abstracting, staging, and follow-up reporting rms q uality control of reg istry d ata usage and reg ular reporting es conte nt of th e annua l report report by Nov ember 1 of the following yea r •Upholds m hair/Physician Liaison Re sponsibilities: gram activ ities through the Ca ncer Comm ittee •Oversees the C ancer Registry in order to assure m aintenance of the Com mission on Can cer accreditation •Relays inform ation from the C ommission on Cancer and the National Cancer Data B ase to the Cancer Com mittee •Compares C ancer Registry statistics to the National Can cer Data Base for discrep ancies and make ap propriate changes in Casefinding procedu res such as adding staff physician' s office the reg istry Cancer Registrar the preparation and publication of the Cancer Prog ram Report liance of the Com mission on Can cer Standards throug h the Cancer Com mittee