Onsite Survey

Certification Survey

All applicant practices are subject to an on-site survey. On-site surveys will be conducted by an experienced oncology certified nurse. The nurse will select and follow patients through chemotherapy administration, examining records, policies, and tools to evaluate all 20 Certification standards.

Before the Visit

Your on-site survey will be scheduled following your submission of chart and standard documentation. You will receive a notice from QOPI Certification staff which will provide you information on the on-site surveyor selected for your practice. Surveyors are chosen in compliance with ASCO and QCP's Conflict of Interest Policy; we ask that your practice confirms that there is no conflict of interest with the selected surveyor. Once this process is complete, your surveyor will contact you directly to find a mutually agreeable date for your survey.

After the Visit

After your on-site survey, your surveyor will write a report which will detail your practice’s concordance with the 20 Certification safety standards, including any requirements for additional documentation. This report is reviewed by QCP staff and then sent to a member of the QOPI Steering Group or QOPI Certification Program Oversight Council for final review and approval.

Your practice should receive its report 4-6 weeks following your on-site visit. Once you receive the report, you will have 10 business days to submit a plan to address any standards deficiencies found during your survey.

Once your plan has been approved, your timeline to submit any additional documentation will depend on your practice’s Certification status. For recertifying practices, your responses will be due 4 weeks prior to the end of the 90 day grace period following your Certification term end date. For new practices, your responses will be due 4 weeks prior to the one-year anniversary of your Certification Pending date.

If a repeated site visit is required to demonstrate practice improvement, the practice will bear the cost of the review including travel and stipends.

QCP On-Site Review – A Day in the Life

QCP On-site Survey: What will our day look like in terms of time?

Time Estimate

Activities

20-30 minutes

Introductions/brief tour of facility/overview of on-site survey activities for the day

 

1-2.5 hours [depending on the flow of the chemotherapy infusion room and the timing of chemotherapy preparation]

 

Review of chemotherapy orders and observation of chemotherapy order checking.

 

Observation of chemotherapy preparation and labeling.

 

Observation of double check of prepared chemotherapy.

 

2-4 Hours

Review of chart documentation for two patients receiving IV chemotherapy and two patients receiving oral chemotherapy (on-site surveyor will select records to review). If possible, this review should occur in an area away from the pharmacy or patient care areas, and a staff member familiar with the EMR/paper chart is needed to assist in locating needed items.

 

Review and/or discussion of policies and procedures for the 20 QCP standards.

 

Review of pharmacy and nursing personnel records (licensure, orientation/training, etc.).

 

1.5 Hour [10-15 minutes each]

 

Interview of 2-3 nurses who administer chemotherapy. Additional interviews of the nurse educator and administrative staff may be requested.  Interviews will occur at a mutually convenient time in a private area away from the patient care area. One nurse is interviewed at a time.

 

Interview of personnel who prepare chemotherapy and/or dispense oral chemotherapy (when applicable).

 

1 – 1.5 Hours

Surveyor in quiet space alone to review notes.

 

30 minutes to 1 hour

 

Exit Summary and discussion (practices may invite whoever they wish to attend)

  • On-site survey observations
  • Timeline for follow up

NOTE: The on-site survey activities do not need to be performed sequentially. The on-site surveyor, in conjunction with the practice staff, will determine the best sequence of survey activities.

How Can You Help To Prepare?

  • Have a quiet, private place available for the surveyor to conduct interviews and review chart documentation, policies, etc.
  • Have current paper or electronic Policies and Procedures related to the 20 standards available and organized. If more than one site is applying for certification, these policies and procedures need to be available for review at all sites.
  • Inform the pharmacy and nursing staff of the purpose of the on-site survey and that the surveyor may be interviewing them or obtaining information from them (all staff who prepare and/or administer chemotherapy, except those in orientation, are eligible to be interviewed for the interview portion of the on-site survey).
  • Reassure the staff that the questions that will be asked, if they are selected to be interviewed, are questions about usual, everyday routines in the practice.
  • Ask infusion room nurses to request the patient’s permission to be observed if selected for observation.

    All QCP on-site surveyors are experienced oncology nurses; as such they understand the demands of clinical practice and the importance of patient safety.  Every effort will be made to ensure that neither is compromised during the on-site survey.