NCRA May 2015
Defensive Abstracting for Quality
Measures, CP3R and RQRS
Introduction
Caron Cunningham – Hulsey, CTR
CTR Coordinator, Field Employee
himagine solutions, inc.
Linda Fine, CTR
National Compliance Manager
himagine solutions, inc.
[email protected]
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Objectives
• Identify the Data Items CP3R and RQRS have in common
• Understand the process to identify & work eligible cases
• Explore ways to proactively collect and report cases
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RQRS
Running Quickly Raging and Screaming
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RQRS
A web based data collection and reporting system
that operates in real clinical time- with the goal of
increasing how well accredited programs adhere
to specific cancer care recommendations in breast
and colorectal patients.
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Cancer Program Practice
Profile Reports CP3R
Offers local providers comparative information to
assess adherence to a standard of care therapies
for major cancers; specifically breast, colorectal,
lung and GI tumors.
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RQRS vs. CP3R Measures
RQRS
CP3R
Radiation therapy is
administered within
one year (365 days) of
diagnosis for women
under age 70 receiving
breast conserving
surgery for breast
cancer.
Radiation therapy is
administered within
one year (365 days) of
diagnosis for women
under age 70 receiving
breast conserving
surgery for breast
cancer.
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RQRS vs. CP3R Measures
RQRS
CP3R
Combination
chemotherapy is
considered or
administered within
four months (120
days) of diagnosis for
women under age 70
with AJCC T1cN0M0 or
Stage II or III hormone
receptor negative
breast cancer.
Combination
chemotherapy is
considered or
administered within
four months (120
days) of diagnosis for
women under age 70
with AJCC T1cN0M0 or
Stage II or III hormone
receptor negative
breast cancer.
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RQRS vs. CP3R Measures
RQRS
Tamoxifen or third
generation aromatase
inhibitor is considered or
administered within one
year (365 days) of
diagnosis for women with
AJCC T1cN0M0 or Stage II
or III hormone receptor
positive breast cancer.
CP3R
Tamoxifen or third
generation aromatase
inhibitor is considered or
administered within one
year (365 days) of
diagnosis for women with
AJCC T1cN0M0 or Stage II
or III hormone receptor
positive breast cancer.
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RQRS vs. CP3R Measures
RQRS
CP3R
Adjuvant chemotherapy
is considered or
administered within
four months (120 days)
of diagnosis for patients
under the age of 80 with
AJCC Stage III (lymph
node positive) colon
cancer.
Adjuvant chemotherapy
is considered or
administered within
four months (120 days)
of diagnosis for patients
under the age of 80 with
AJCC Stage III (lymph
node positive) colon
cancer.
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RQRS vs. CP3R Measures
RQRS
CP3R
Radiation therapy is
considered or
administered within six
months (180 days) of
diagnosis for patients
under the age of 80 with
clinical or pathologic AJCC
T4N0M0 or Stage III and
who are receiving surgical
resection for rectal cancer.
Radiation therapy is
considered or
administered within six
months (180 days) of
diagnosis for patients
under the age of 80 with
clinical or pathologic AJCC
T4N0M0 or Stage III and
who are receiving surgical
resection for rectal cancer.
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Additional CP3R
• At least 15 regional lymph nodes are removed and
pathologically examined for resected gastric cancer.
• At least ten (10) regional lymph nodes are removed and
pathologically examined for AJCC stage IA, IB, IIA, and IIB
resected NSCLC.
• Systemic chemotherapy is administered within 4 months
to day preoperatively or day of surgery to 6 months
postoperatively, or it is considered for surgically resected
cases with pathologic, lymph node-positive (pN1) and
(pN2) NSCLC.
• At least 12 regional lymph nodes are removed and
pathologically examined for resected colon cancer.
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Achievement
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Staffing Tips
• Identify the Time needed weekly/monthly
• Dedicate a portion of an FTE to the process
• Assign the same person or divide the tasks among
staff so it fits into their normal routine
• Choose a day to work these weekly/monthly
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Casefinding Tips
• Set up a rapid casefinding system
• Identify ways within your system to collect, breast,
colorectal, lung & gastric quickly
• Establish a workflow process weekly/monthly
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Abstracting Tips
• Work toward Concurrent Abstracting
• Identify best sources for Data Needed
• Set up a Process to List What’s Needed
(Incompletes)
• Establish a Timeline to Find & Add Missing Data
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Transmission Plan
• Work toward multiple transmits
• Steadily Increase the Number of Transmits
• Strive to Make Weekly Reporting a Goal
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Benefits
• Alerts Staff to Prevent Treatment Delays
• Prevents Patients Falling Through the Cracks
• Moves Registry from Passive Reporting Tool to
Active Patient Alert and Compliance Resource
• Improves Cancer Registry Visibility & Value
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Resources
• American College of Surgeons, Commission on
Cancer
• www.facs.org/cancer/ncdb/registrars
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Questions?
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