Certification Standards

The QOPI Certification Site Assessment is a review of the practice’s/institution’s concordance with structural quality standards.  When a practice applies for Certification, their policies and procedures will be assessed against the Certification Safety Standards. Practices will be asked to submit documentation of their compliance with the Certification Standards and required to participate in an on-site review to assess their compliance. All practice sites must be compliant with all of the Certification Safety Standards before Certification can be awarded.

The standards listed below are current as of January 2017. To download a PDF copy click here.

 

QOPI Measures leaf page- QCP Standards

Common Definitions for Chemotherapy Administration Safety Standards

Chemotherapy - All antineoplastic agents used to treat cancer, given through oral and parenteral routes or other routes as specified in the standard. Types include targeted agents, alkylating agents, antimetabolites, plant alkaloids and terpenoids, topoisomerase inhibitors, antitumor antibiotics, monoclonal antibodies, and biologics and related agents.  Hormonal therapies are not included in the definition of chemotherapy for the standards.

Chemotherapy regimen - One or more chemotherapeutic agents used alone or in combination in a well-defined protocol, generally administered cyclically.

Practitioner - Licensed independent practitioner, including physicians, advanced practice nurses (nurse practitioner or clinical nurse specialist), and/or physician assistants, as determined by state law.

Chemotherapy setting (site) - All chemotherapy treatment settings (inpatient and outpatient).

Adherence - The degree or extent of conformity to the provider’s recommendations about day-to-day treatment with respect to timing, dosing, and frequency.

Clinical encounter - Clinical encounters include each inpatient day, practitioner visits and chemotherapy administration visits, but not laboratory or administrative visits.

Staffing Related Standards

1. The practice/institution has policies, procedures, and/or guidelines for verification of training and continuing education for clinical staff: 

a. Orders for parenteral and oral chemotherapy are written and signed by licensed independent practitioners who are determined to be qualified by the practice/institution according to the practice’s/institution’s policies, procedures, and/or guidelines.

b. Chemotherapy drugs (oral or parenteral) are prepared by a pharmacist, pharmacy technician, or nurse determined to be qualified according to the practice’s policies, procedures, and/or guidelines.

c. Only qualified physicians, physician assistants, advanced practice nurses, or registered nurses administer chemotherapy. 

d. The practice/institution has a comprehensive educational program for new staff administering chemotherapy, including a competency assessment, or the practice/institution uses an established educational program regarding chemotherapy administration that ends in competency assessment. Education and competency assessment regarding Chemotherapy administration includes all routes of administration used in the practice/institution site (e.g., parenteral, oral, intrathecal, intraperitoneal, intravesicular), and safe handling of hazardous chemotherapy agents. An example of an established educational program is the ONS Chemotherapy and Biotherapy Course. 

e. The practice/institution has a standard mechanism for monitoring chemotherapy administration competency at specified intervals. Annual competency reassessment is recommended.

f. There must be at least one clinical staff member who maintains current certification in basic life support on site during chemotherapy administration in the health care setting. Certification should be from a nationally accredited course. Clinical staff includes staff involved in patient care; RNs, MDs, NPs, etc. 

Chemotherapy Planning: Chart Documentation Standards

2. Before the first administration of a new chemotherapy regime n, chart documentation available to the practice /institution includes:

  • Pathologic confirmation or verification of initial diagnosis.
  • If original pathology report is unobtainable, note of explanation is in chart or a reference to primary source pathology.
    • This standard does not imply the need to re-biopsy if not clinically necessary.
  • Initial cancer stage or current cancer status.
  • Cancer stage is defined at diagnosis. Cancer status includes a current description of the patient’s disease since diagnosis/staging, if relevant (e.g., recurrence, metastases).
  • Complete medical history and physical examination that includes, at minimum, height, weight, pregnancy screening (when applicable), and assessment of organ-specific function as appropriate for the planned regimen.
  • Example of assessment of organ-specific function as appropriate for the planned regimen: patient plan for cisplatin requires pretreatment assessment of kidney function.

  • Presence or absence of allergies and history of other hypersensitivity  reactions
  • Documentation of patient’s comprehension regarding chemotherapy regimens (and associated medications), including information regarding disease.
  • Assessment regarding psychosocial concerns and need for support, with action taken when indicated.
  • Documentation of psychosocial concerns may include: copy of distress, depression, or anxiety screening form in the chart; patient self -report of distress, depression, or anxiety; or chart documentation regarding patient coping, adjustment, depression, distress, anxiety, emotional status, family support and care giving, coping style, cultural background, and socioeconomic status.

  • The chemotherapy treatment plan, including, at minimum, chemotherapy drugs, doses, anticipated duration, and goals of therapy.
  • For oral chemotherapy, the frequency of office visits and monitoring that is appropriate for the individual and the antineoplastic agent and is defined in the treatment plan.
General Chemotherapy Practice Standards

3. The practice /institution maintains a policy for how informed consent is obtained and documented for chemotherapy.

The practice/institution may provide options for consent (e.g., use of chart documentation of patient consent or a signed patient consent form) that allow for variation among practitioners in the practice/institution.

Chemotherapy Order Standards

4.Order forms inclusively list all chemotherapy agents in the regimen and their individual dosing parameters. All medications within the order set are listed using full generic name s and follow Joint Commission standards regarding abbreviations.

Brand names should be included in orders only where there are multiple products or when including the brand name otherwise assists in identifying a unique drug formulation.

Complete orders must include:

  • Patient’s full name and a second patient identifier  (e.g., medical record number, DOB)
  • Date
  • Diagnosis
  • Regimen name and cycle number
  • Protocol name and number (if applicable)
  • Appropriate criteria to treat (e.g., based on relevant laboratory results and toxicities)
  • Allergies
    • Reference to the methodology of the dose calculation or standard practice equations (e.g., calculation of creatinine clearance)
  • Height, weight, and any other variables used to calculate the dose
  • Dosage
  • Doses do not include trailing zeros; use a leading zero for doses <1 mg.
  • Route and rate (if applicable)  of administration
  • Length of infusion (if applicable)
  • Supportive care treatments appropriate for the regimen (including  pre-medications, hydration, growth factors, and hypersensitivity medications)
  • Sequence of drug administration  (if applicable)
    • Practices/institutions are not expected to be in full compliance with this standard if they currently have electronic ordering systems that prevent compliance. Appropriate changes should be implemented as soon as possible to ensure that electronic ordering systems integrate all of these elements. If the information cannot be captured in the electronic system, it should be documented within the patient record.
Drug Preparation

5. A second person (a practitioner or other personnel approved by the practice /institution to pre pare or administer chemotherapy) independently verifies each order for chemotherapy before preparation, including confirming:

  • Two patient identifiers
  • Drug names
  • Drug dose
  • Drug volume
  • Route of administration
  • Rate of administration
  • The calculation for dosing (including  the variables used in this calculation)
  • Treatment cycle and day of cycle

6. Chemotherapy drugs are labeled immediately upon preparation, including, at minimum:

  • Patient’s full name and a second patient identifier  (e.g., medical record number, DOB)
  • Full generic drug name
  • Drug administration  route
  • Total dose to be given
  • Total volume required to administer this dosage
  • Date of administration
  • Date and time of preparation
  • Date and time of expiration when not for immediate use*

*Immediate use must be defined by institutional policy, state, and federal regulations (e.g. use within 2 hours). Practices/institutions are not expected to be in full compliance with this standard if they currently have electronic systems that are unable to meet these labeling requirements. Appropriate changes should be implemented as soon as possible to ensure that electronic labels integrate all of these elements. 

7. Practice s/institutions that administer intrathecal medication maintain policies specifying that intrathecal medication will:

  • Not be prepared during preparation of any other agents.
  • Be stored, once prepared, in an isolated container or location with a uniquely identifiable intrathecal medication label.
  • Be delivered to the patient only with other medication intended for administration into the CNS.
Chemotherapy Administration

8. Before chemotherapy administration:

A practitioner who is administering  the chemotherapy confirms with the patient his/her planned treatment prior to each cycle:

  • At least two practitioners or personnel approved by the practice/institution to prepare or administer chemotherapy, verify the accuracy of:
  • Drug name
  • Drug dose
  • Drug volume
  • Rate of administration
  • Route of administration
  • Expiration dates/times; if applicable; expiration date/time is not required if for immediate use
  • Appearance and physical integrity of the drugs
  • Rate set on infusion pump, when utilized
    • A practitioner who is administering  the chemotherapy documents that the verification in B was done
    • At least two individuals, in the presence of patient, verify the patient identification using at least two identifiers  (e.g., medical record number, DOB)
    • *Immediate use must be defined by institutional policy, state, and federal regulations (e.g. use within 2 hours). 

9. Extravasation management procedures are defined and align with current literature and guidelines;

  • A. Antidote order sets
  • B. Antidotes are accessible
Monitoring and Assessment

10. The practice /institution maintains protocols for response to life threatening emergencies, including escalation of patient support be yond basic life support.

It is recommended that emergency protocols are reviewed annually. 

11. On each clinical visit or day of treatment during chemotherapy administration, staff:

  • Assess and document clinical status and/or performance status
  • Document vital signs and weight
  • Verify allergies, previous reactions, and treatment-related toxicities
  • Assess and document psychosocial concerns and need for support; taking action when indicated.

This standard applies to all clinical encounters (including each inpatient day, practitioner visits and chemotherapy administration visits, but not laboratory or administrative visits).

For the purpose of Certification; section C “known allergies” and section D “psychosocial assessment” do not need to be assessed more than once per week. [i.e. during multi-day treatments]

12. At each clinical encounter, staff re vie w the patient’s current medications including over-the - counter medications and complementary and alternative therapies. Any change in the patient’s medications prompts are view for drug-drug interactions.

This standard applies to all clinical encounters (including each inpatient day practitioner visit and chemotherapy administration visits but not laboratory or administrative visits).

For the purpose of Certification standard 12 does not need to be assessed more than once per week [i.e. during multi-day treatments].

13.     The practice /institution maintains referral re source s for psychosocial and other supportive care services.

14.     The practice /institution e stablishes a procedure for documentation and follow-up for patients who miss office visits and/or scheduled chemotherapy treatments.

15.     The practice /institution has policies and procedures that identify:

  • A process to provide 24/7 triage to a practitioner (e.g. on-call practitioner, emergency department) for care of toxicities
  • If an oncology LIP does not provide initial triage, a mechanism to provide oncology consultation must be available 24/7.
  • This should include a policy to define how to transfer a patient to a center with oncology expertise, if needed.
  • Practices in rural low population areas should consult with QCP staff in unable to comply with the standard.

16.   Toxicity assessment documentation is available for planning subsequent treatment cycles.

17.   The practice /institution has a process to track cumulative dose s of chemotherapy agents associate d with a risk of cumulative toxicity.

18.   The practice /institution maintains a plan for ongoing and regimen-specific assessment of e ach patient’s oral chemotherapy adherence and toxicity. The policy includes, at minimum, patient assessment for adherence and toxicity at each clinical encounter at the practice /institution, as well as a plan for clinical staff to address any issues  identified.

Patient Consent and Education

19. Before initiation of a chemotherapy regimen, e ach patient is given written and/or electronic information, including, at minimum:

  • Information regarding his/her diagnosis
  • Goals of therapy
  • Planned duration of chemotherapy, drugs, and schedule
  • Information on possible short-and long-term adverse effects, including infertility risks
  • Regimen-or drug-specific risks or symptoms that require notification and emergency contact information, including:
    • How to contact the practice or organization
    • Symptoms that should trigger a call
    • Who should be called in specific circumstances (oncologist  or other provider)
  • Plan for monitoring  and follow-up, including appointments with the practitioners or laboratory testing

Patient education materials should be appropriate for the patient’s reading level/literacy and patient/caregiver understanding. Documentation should include patient f eedback reflecting understanding and engagement.

20. Informed consent for chemotherapy must be documented prior to initiation of a chemotherapy regimen.

The consent process should follow appropriate professional and legal guidelines. For more information and sample forms, see http://www.asco.org/consent.

Note:   Informed consent for chemotherapy must be document e d prior to initiation of a chemotherapy regimen. The consent process should follow appropriate professional and legal guidelines. For more information and sample forms, see http://www.asco.org/consent.

All standards are from Neuss, MN. Jacobson JO, Polovich M, Polovich M, et al: 2013 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards Including Standards for the Safe Administration and Management of Oral Chemotherapy. J. Oncol. Pract. 2013;9:5s-13s.

The current version of these consensus standards reflects modifications that are intended to extend the standards to address the safe use of oral chemotherapeutic agents. The American Society of Clinical Oncology/Oncology Nursing Society (ASCO/ONS) standards are intended to reflect current thinking on best practices and, as such, are intended to be a “living” document; future modifications are expected.

Although the ASCO/ONS standards were not developed to address this issue, ASCO and ONS endorse the safe handling of chemotherapy agents. Published guidelines define the expectations for organizations and health care workers related to the use of safe handling precautions (American Society of Health System Pharmacists: Am J Health Syst Pharm 63:1172-1193, 2006; National Institute for Occupational Safety and Health: DHHS publication No. 2004-165, 2004; Occupational Safety and Health Administration: OSHA technical manual, 1995; Polovich M et al: Pittsburgh, PA, Oncology Nursing Society, 2009; US Pharmacopeia Convention, Rockville, MD, 2008). Education,  training,  and competency validation for chemotherapy administration must necessarily include this aspect of practice. Organizations should focus on a culture of safety, because of the relationship between patient and health care worker safety (Friese CR et al: BMJ Qual Saf, 2011; Polovich M, Clark PC: Oncology Nursing Forum, 2012).