Making Sense of the Rapid Quality Reporting System

The new standard and evolving practice for cancer registry benefits patient care and facilities

Introduction

The Rapid Quality Reporting System (RQRS) provides valuable incentives and benefits to hospitals implementing it, including improved patient outcomes, the ability to negotiate favorable reimbursement with payers by demonstrating their quality of medical practice, and commendation for Standard 5.2 of the American College of Surgeons (ACoS) Commission on Cancer’s (CoC) Cancer Program Standards.

Challenges can be expected with any new system implementation, including staffing, training and I.T. infrastructure upgrades; therefore, all hospitals must weigh the benefits and challenges of RQRS participation. Those moving forward can take steps to significantly increase their odds of success. The RQRS provides the next logical step in utilizing the cancer registry to positively impact patient outcomes and the quality of medical practice.

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As defined by Standard 5.2 of the CoC Cancer Program Standards 2012, Version 1.2.1: Ensuring Patient-Centered Care, the CoC developed the RQRS to:

“… facilitate quality improvement by encouraging evidence-based care in CoC-accredited programs for select quality measures. RQRS enables accredited cancer programs to report data on patients concurrently, receive notifications of treatment expectations, and presents year-to-date concordance rates for each measure as compared to the state, other hospital groups, and hospitals at the national level.” The primary objective of the RQRS is to promote evidence-based cancer care at the local level through real clinical time compliance monitoring and assessment of four National Quality Forum-endorsed measures and two surveillance measures for cancer care for breast and colorectal cancer patients.i The RQRS does not test new interventions, but rather, offers a systematic data collection and reporting system for promoting evidenced-based treatments.

A web-based system, the RQRS also provides alerts to support the anticipated scope of care

What is the RQRS?

coordination required for breast and colorectal cancer patients at local facilities. The RQRS reports the same quality measures for breast and colorectal cancer care as those endorsed by the National Quality Forum or identified though collaboration with other national medical and oncology organizations and societies. CoC-accredited hospitals currently receive reports of these measures but rely on the collection and analysis of retrospective data, often more than 18-24 months old. The RQRS provides a significant advantage by reporting these data in real clinical time.ii

In 2014, the RQRS standard became one of seven criteria for the CoC Outstanding Achievement Award. This standard is currently valid for programs previously accredited by the CoC and is for commendation only.

Hospitals need the RQRS

The quality of cancer care in the United States varies widely, and variation in care affects outcomes ranging from quality of life and resource utilization, to cancer recurrence and long-term survival. Addressing variation and quality of cancer care became a national priority when the National Cancer Policy Board of the Institute of Medicine published “Ensuring Quality Cancer Care” in 1999. The report outlined the scope of the problem and broad recommendations for quality improvement.

Cancer care requires a unique system to measure performance and improvement. Compared to quality initiatives in cardiac care which can focus primarily on single episodes of inpatient care (e.g. cardiac surgery outcome and treatment of acute myocardial infarction), quality evaluation in cancer care cannot be limited to the inpatient setting. Cancer care remains the sum of multiple episodes of care, often spread over weeks or months, administered by a number of providers across different specialties in a combination of inpatient and ambulatory settings. For example, a significant proportion of cancer care for common malignancies now gets administered in the ambulatory setting.

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Because of these unique challenges, quality improvement of cancer care requires evidenced-based measures that can be applied with available data while maintaining relevance to providers, institutions and consumers across a number of settings.iii

Participation in the RQRS

Currently voluntary, evidence suggests that participation in the RQRS may become mandatory for all CoC-accredited cancer programs in the future. For now, to participate in the RQRS, a facility must be an accredited cancer program through the ACoS CoC, with the Hospital Registrar, Cancer Liaison Physician, Cancer Committee Chairperson and Cancer Program Administrator all agreeing to participate, register, have access to CoC Datalinks and provide up-to-date email contact information.

Separate enrollment by each individual for RQRS ensures key members of the cancer program understand the responsibilities and value of RQRS participation and helps achieve the greatest possible impact on quality improvement and patient care. Similarly, to withdraw from participation, all parties must agree and complete the appropriate steps.

Data must be submitted at least every three months (quarterly), though preferably with greater frequency.iv

Benefits of the RQRS

Implementing and utilizing the RQRS provides a number of facility and patient care benefits.

Facility BenefitsThe facility receives timely data and notifications of treatment expectations including reports from the National Cancer Database (NCDB) on cases that fall out of compliance with Cancer Program Practice Profile Reports (CP3R); improved

Hospitals need the RQRS (continued)

treatment information completeness across all primary cancer sites; and visibility into the cancer program’s up-to-date concordance rates relative to the state, other similar programs and all CoC-accredited programs across the country. RQRS participation also boosts the cancer registry’s perceived value by providing timely, useful and meaningful data. It enables expedited data entry of a critical subset of items specifically relevant to anticipated standard of care treatments and enables accredited cancer programs to report data on patients concurrently. With timely data, the cancer registry’s role at multidisciplinary cancer conferences may shift from a support role to a participant role (i.e. educating medical staff on existing National Quality Forum and CoC recommendations, identifying patients’ diseases that qualify for tracking through RQRS as well as CP3R), displaying the facility’s dedication to improving and monitoring patient care concurrently rather than retrospectively.

Utilizing the RQRS also puts facilities in a stronger position to negotiate favorable reimbursement with payers by better demonstrating the quality of medical practice.

Finally, by implementing the RQRS, the facility becomes eligible for a CoC commendation for Standard 5.2, so long as it adheres to the following criteria:v

“From initial enrollment and throughout the three-year accreditation period, the program participates in RQRS, submits all eligible cases for all valid performance measures, and adheres to RQRS terms and conditions.”

Patient Care BenefitsWith the RQRS, concurrent abstraction provides real time data which reflects current cancer treatment practices and enables better clinical decisions. While the cancer registry has served as the best resource for cancer treatment practices and outcomes, concurrent abstracting ensures that physicians, surgeons and other cancer-care team members have access to the most current data to inform their decisions. Concurrent abstraction can also help improve patient outcomes by catching patients before they fall through the cracks by reducing delays for both referral and treatment.

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Patient outcomes can see positive effects from increased teamwork, as the RQRS promotes the coordination of care and enhances the quality of adjuvant therapy information in the cancer registry. This promotes organizational confidence in the registry and usage among the physicians and ancillary staff responsible for the coordination of care.

Since the RQRS provides a wealth of timely cancer data, physicians and researchers can utilize it to access detailed data for completing and publishing cancer studies. The RQRS reduces the need for direct access to patients being treated for cancer to gather data, therefore resulting in less expensive and better studies, potentially leading to improved patient outcomes.

Challenges associated with RQRS

As with any new implementation, hospitals should expect new challenges to arise, chief among them, an increased and evolving workload for certified tumor registrars (CTRs). Daniel P. McKellar MD, FACS, Chair of the Commission on Cancer, reported at 2013 Survey Savvy that based on a RQRS caseload of 161 cases per year and per CTR and focusing on the initial six measures identified in RQRS, an increased workload approximately equal to 0.7 abstractions per day and per CTR can be expected.vi Anecdotally, we’ve heard firsthand accounts of 16-28 hour monthly workload increases for CTRs, but average totals have yet to be officially reported.

Expect further workload increases as the number of RQRS cancer sites for reporting has already expanded and will likely continue growing in the foreseeable future. In Version 3, RQRS added three new breast measures and one rectal measure (revised in the CP3R program). In 2014, four lung measures, two gastric measures and one esophageal measure are planned to be added to CP3R and reported in RQRS. Minimally, this means seven new sites reported with additional measures under evaluation for CP3R, including ovarian, endometrial, cervical, G/U, melanoma, sarcoma and pediatric oncology. This potentially creates a total of 25 quality measures

Benefits (continued)

reported via RQRS, substantially increasing the staff resources needed to participate in the program.

More rigorous educational requirements have reduced the number of prospective students willing to qualify to sit for the CTR exam. As fewer professionals enter the CTR talent pool, the profession also loses people each year. Over the last 10 years, an average of 135 CTRs have left the talent pool each year, creating more open positions and a widening gap between supply and demand.

The RQRS also increases demands on I.T. departments. They must sort out product use limitations (number of available licenses and product restrictions) and ensure staff can provide the technical support needed to institute and maintain the RQRS implementation.

While the challenges may seem too great to overcome RQRS’ voluntary status, facilities may not have a choice much longer as McKellar noted that the CoC could, “Possibly move towards requiring RQRS for all cancer programs in the future.”

Small steps today for big benefits

The benefits of the RQRS are clear, but due to its infancy (introduced in late 2011) and its optional status, those benefits are not well documented yet. Still, taking a few small steps today to prepare the facility for RQRS implementation can provide a big payoff.

First, discuss plans to implement the RQRS with the Hospital Registrar, Cancer Liaison Physician, Cancer Committee Chairperson and Cancer Program Administrator. It is critical to get buy-in from all four parties since all must participate.

Next, consider the increased workload. Adequate staffing and support of the cancer registry will ensure RQRS participation works most effectively. Staff will need time to master concurrent abstraction, follow cases from diagnosis through the end of treatment, and follow up with treating physicians regularly to determine the treatment status of RQRS cases with alerts. It is critical to enable physician participation in this process as RQRS case alerts may be reviewed

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Small steps (continued)

in cancer conferences or at cancer committee meetings. Physicians may need to reach out to their peers to promote compliance with the measures or cooperation with the cancer registry.

Finally, RQRS implementation could require an I.T. infrastructure upgrade. All RQRS users’ workstations must be equipped with Adobe Flash Player v10.3 and one of the following Internet browser programs:

l Internet Explorer 8 or abovel Google Chrome 13.0 or abovel Mozilla Firefox 3.6 or abovel Safari 5.2

Cases transmitted to RQRS use the same secure electronic data transmission protocols utilized by the NCDB established in 2001, and transmission files for RQRS must match the format used for the NCDB annual call for data.

Taking these steps positions the facility for a big payoff, including improved patient outcomes, the ability to negotiate favorable reimbursement with payers by demonstrating the quality of medical practice and potential commendation for Standard 5.2 of the ACoS CoC Cancer Program Standards. Early adopters of RQRS have already experienced the benefits:vii

“[My favorite part of RQRS is] seeing our compliance percentages improve and knowing our patients are receiving quality care.” — Cancer Registrar

“I think [RQRS] is good for the institution. It serves to compare their own practice with the accepted norms and accomplishes it in real time instead of [using] retrospective data. Patients obtain benefits from the real-time correction.” — Cancer Physician

Resourcesi Commission on Cancer. What is RQRS Flyer. American

College of Surgeons. http://www.facs.org/cancer/ncdb/rqrsflyer.pdf. Accessed April 18, 2014.

ii Commission on Cancer. RQRS Overview. American College of Surgeons. http://www.facs.org/cancer/ncdb/rqrsoverview.pdf. Published August, 2011. Accessed April 18, 2014.

iii Commission on Cancer. RQRS Overview. American College of Surgeons. http://www.facs.org/cancer/ncdb/rqrsoverview.pdf. Published August, 2011. Accessed April 18, 2014.

iv Commission on Cancer. RQRS Terms and Conditions. American College of Surgeons. http://www.facs.org/cancer/ncdb/rqrs_terms.pdf. Published September 19, 2011. Accessed April 18, 2014.

v Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient-Centered Care. American College of Surgeons. http://www.facs.org/cancer/coc/programstandards2012.pdf. Published September, 2012. Accessed April 18, 2014.

vi Mckellar, Daniel P. RQRS - A New Standard and Evolving Practice. Paper presented at: 2013 Survey Savvy; June, 2013; Chicago, Illinois.

vii Commission on Cancer. RQRS Getting Started. American College of Surgeons. http://www.facs.org/cancer/ncdb/rqrs-gettingstarted.pdf. Accessed April 18, 2014.

Laurie Hebert, RHIA, CCS, CCS-P, CTRVice President and General Manager, Cancer Registry Serviceslhebert@care-communications.com

800-458-3544, Ext. 161

As Vice President and General Manager, Cancer Registry Services at Care Communications, Inc., Laurie Hebert manages client relationships, cancer registry consultants, and sales of cancer registry services, while providing input and oversight for research projects that require cancer registry data. Laurie formerly served on the National Cancer Registrars Association’s Board of Directors as Advocacy and Technical Practice Director-Midwest, and is the past chair of the association’s National Cancer Registrars Week Committee. She is past president-elect of the Central Louisiana Health Information Management Association and past president of the Southeast Louisiana Health Information Management Association.

Laurie has published or contributed to many articles noted in national trade publications, authored white papers related to the cancer registry field, co-authored a study on pediatric lymphoma, and assisted in the development of a pediatric staging form chosen by the American College of Surgeons Commission on Cancer as a best practice tool for pediatric facilities. She has also given education presentations related to the cancer registry profession.

Theresa Vallerand, BGS, CTRManager of Cancer Registry Servicestvallerand@care-communications.com

800-458-3544, Ext. 135

Theresa Vallerand is Manager of Cancer Registry Services for Care Communications, Inc., where she supports cancer registry consultant staff and serves as a client relations manager for cancer registry clients. Previously, Theresa worked as a cancer registrar in community and teaching hospitals and a state central registry. She is past president of the Cancer Registrars Association of New England, Inc. She currently serves on the National Cancer Registrars Association’s (NCRA) Board of Directors as the Public Relations and Communications Board Director. She is also currently the chairperson for the Policies and Procedures Committee, and the former Ethics Committee chairperson for NCRA.

Theresa has written several articles for the “Registry Perspectives” column of ADVANCE for Health Information Professionals and has given educational presentations related to the cancer registry profession.

Jennifer Zahn, CTRManager of Cancer Registry Servicesjzahn@care-communications.com

800-458-3544, Ext. 189

Jennifer Zahn is Manager of Cancer Registry Services for Care Communications, Inc., where she supports cancer registry consultant staff and serves as a client relations manager for cancer registry clients. Previously, she worked as a cancer registrar with community hospitals, and as a cancer registry quality assurance team member for the State of Wisconsin WI CARE project.

She is past president of the Wisconsin Cancer Registrars Association after many years as an executive committee member. She has contributed to multiple articles in ADVANCE for Health Information Professionals.

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About the Authors