Preparing for an accreditation or certification survey is key to ensuring a cancer program’s success. Understanding survey expectations and preparing the clinical team can alleviate the survey stress. Although oncology accreditation or certification surveys evaluate the care provided by the entire multidisciplinary team, oncology nurses are central to these surveys because of their pivotal role in providing high-quality care to oncology patients.
What Is QOPI?
The American Society of Clinical Oncology (ASCO) is an organization that sets quality measures and standards for cancer programs. The Quality Oncology Practice Initiative (QOPI®) Certification Program provides a 3-year certification recognizing high-quality care for outpatient hematology-oncology practices within the United States. Practices can benchmark their performance against other QOPI-designated practices to ensure theirs delivers the best care for patients and “demonstrates its commitment to quality to patients, payors, and the medical community.”
For QOPI Certification, a practice undergoes an on-site or virtual survey to ensure compliance with QOPI Certification Standards. Below are best practices for preparing for a QOPI survey—knowing your resources, preselecting patients, and practicing. These same steps could also apply to preparing for other types of oncology accreditation or certification surveys, such as:
- Commission on Cancer (CoC)
- National Accreditation for Breast Cancer Programs (NAPBC)
- Foundation for the Accreditation of Cellular Therapy (FACT)
Knowing Your Resources
The ASCO website shares resources to help oncology practices know what to expect during QOPI accreditation–the most pertinent being its QOPI® Certification Program Standards. Each domain includes how to interpret the standards and their elements, required written materials, what the surveyor must observe during the survey, and the outcomes the practice will have in place after implementing the standards.
The online QOPI application requires pre-survey documentation, including abstracted charts, a practice questionnaire, and policies and procedures. In addition, ASCO hosts several webinars to help practices understand the requirements. By using the QOPI standards, an oncology practice can then perform a gap analysis of both clinical practice and its policies and procedures to ensure both comply with standards.
Preselecting Patients for Survey Day
To guarantee the best practices outlined in policies and procedures are in place in clinical practice, QOPI surveyors will follow staff members caring for oncology patients. Therefore, oncology practices can choose which patients for surveyors to observe. Because QOPI standards focus on chemotherapy administration safety, selecting a patient receiving treatment who will allow the surveyor to watch the entire administration process from start to finish is essential. The survey also involves medical record review, so oncology nurses can help select patients whose clinical documentation highlights QOPI standards, such as informed consent, patient education, and discharge information.
Practicing for the Survey
Performing a “dress rehearsal” or “mock” survey is a great way to increase the oncology team’s confidence for the day of the survey. One best practice is to create a question and answer document from the standards to share with the nursing team. Some questions might include the following:
- What is the process for obtaining and documenting informed consent?
- How do you educate patients about their treatment plan, and what does it include?
- How does the team verify chemotherapy orders?
- What is the training to administer chemotherapy? How do you maintain competency?
- How does your practice handle patient no-show appointments?
- How can patients in your practice access an oncology provider 24/7?
Managers and educators can interview staff in the weeks leading up to the survey, allowing them to practice their responses. Oncology nurses should be confident in explaining their care, verbalizing their written policy and procedures, and sharing their clinical documentation in the medical record. They must also be prepared to share proper steps in the event of an oncologic emergency event, such as an extravasation or an infusion reaction.
Preparation is key to ensuring a successful QOPI on-site survey. Although accreditation or certification surveys can be very time consuming and require much effort, the preparation can reveal areas for quality improvement. Ultimately, lessons learned can improve the quality of patient care and potentially affect patient outcomes.
References
Quality Oncology Practice Initiative (QOPIâ)
QOPI® Certification Program Standards
