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Qmentum Program

STANDARDS

Cancer Populations

Accredited by ISQua
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Qmentum Program

Published by Accreditation Canada. All rights reserved. No part of this publication may be
reproduced, or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without proper written permission from Accreditation
Canada.
Accreditation Canada, 2009
Cancer Populations
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Accreditation Canada's Standards for Cancer Populations are based on:

Wagner et als Chronic Care Model that has been adopted in many provinces and organizations across
Canada1
the Expanded Chronic Care Model developed in British Columbia 2
input from an expert multi-disciplinary standards working group, and
an extensive review of research and best practice in cancer care.

These standards are for use by health regions or by organizations with a regional mandate that manage and
coordinate services for populations with, at risk for, or affected by cancer. The standards emphasize a primary
health and population-based approach to integrating cancer services across the continuum of care, from
disease prevention through treatment, self-management, and rehabilitation.
Accreditation Canada has also developed standards for cancer services. Unlike the standards for cancer
populations, which focus on excellence at the regional level across the continuum of care, the Standards for
Cancer Care and Oncology Services address quality and safety at the service delivery level, focusing on care
and treatment in acute or institutional settings. The two sets of standards are complementary, designed to be
used together where appropriate to coordinate and evaluate the complex reality of cancer services in Canada.
Most services for people with cancer are delivered by primary care providers in the community. Accreditation
Canadas population standards address the importance of primary care, the need to align acute and tertiary
care to support the services provided by primary care providers, and the importance of integrating services
across the continuum of care.
These standards contain the following subsections:

Investing in cancer services


Partnering with the community
Integrating and coordinating services
Supporting clients to self-manage their care and symptoms
Basing decisions on research and evidence
Using information and information technology
Monitoring quality and achieving positive outcomes

Global Perspectives on Chronic Disease Management: The Calgary Conference 2005. Calgary, Alberta. September 25-29, 2005
and Innovations in Rural Chronic Care: The Beulah Sault Seniors Health Conference 2006. Lethbridge, Alberta. April 12-13, 2006.
2

Barr VJ et al, (2003). The Expanded Chronic Care Model: An Integration of Concepts and Strategies from Population Health
Promotion and the Chronic Care Model. Submitted for publication March 31, 2003.

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Cancer Populations
INVESTING IN CANCER SERVICES
1.0

The organization supports services for cancer populations.


1.1

Population Focus

The organization addresses the needs of cancer populations in its strategic and
operational plans.
Guidelines
The organizations plans demonstrate the value of its cancer control services.

1.2
Population Focus

The organization dedicates resources to services and programs for cancer


populations.
Guidelines
When dedicating resources to services and programs, the organization considers the
sustainability of resources and funding. The organization also pursues opportunities to
collaborate and share resources with partners and other organizations.

1.3
Worklife

The organization bases incentives and benefits for staff and service providers on
the quality of cancer services provided.
Guidelines
Incentives and benefits are linked to service quality rather than volume of service. They
may include payment and remuneration structures, a case mix that is adjusted for
complexity of the condition, or rewards tied to client outcomes.
Where services and remuneration are regulated by provincial governments, the
organization may develop other incentives to promote better quality of services for
populations with cancer.

1.4
Effectiveness

The organization sets measurable and specific goals and objectives for its
services for populations with cancer.
Guidelines
The goals and objectives describe what the organization wants to achieve for cancer
services. They are linked to the organizations strategic direction, have measurable
outcomes and success factors, and are realistic and time-specific.

1.5
Effectiveness

The organization defines how it will achieve its strategic direction, goals, and
objectives for cancer populations.
Guidelines
Methods to achieve the strategic direction, goals, and objectives may include system
redesign, resource allocation, and program planning and design.

1.6
Effectiveness

The organization supports the achievement of its goals and objectives for cancer
populations.
Guidelines
For example, the organization may have identified an executive sponsor who is
responsible for cancer services.

2.0

The organization identifies the service needs of cancer populations.

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2.1
Population Focus

The organization collects information about the service needs of cancer


populations in the community.
Guidelines
Sources of information may include a clinical information system, public health or
surveillance information, and other service providers or organizations.
Population information includes demographic characteristics such as age and sex,
common risk factors for cancer, information about cancer site or diagnostic
categorizations, and unique population groups including underserved, elderly, paediatric,
or aboriginal communities.
Many of the risk factors for cancer are common to other chronic diseases. These include
unhealthy eating, physical inactivity, overweight/obesity, smoking, alcohol abuse, and
psychological distress. In addition, the impact of social determinants of health such as
housing, education, and socioeconomic status can greatly increase the risk for disease.
There are also risk factors that are unique to cancer, such as sun exposure.
The organization identifies the risk factors that have an impact on the populations it
serves and uses this information to plan future services.

2.2
Population Focus

The organization uses the information it collects to classify populations according


to the need for programs and services.
Guidelines
Classifying populations may help the organization tailor its services to better meet the
needs of the populations it serves.
For example, a pyramid approach can be used to classify populations according to the
need for health services. For cancer populations, the base of the pyramid would be
defined as an essentially healthy population where the focus is on health promotion and
cancer prevention. The middle would include individuals with, or at risk for, cancer, where
the focus is on cancer treatment, symptom management, and secondary prevention of
cancer, metastases, or emotional distress. The top includes those with acute cancer, with
one or more cancer site, metastatic, and terminal cancers who require complex pain and
symptom management and strategies to delay or prevent the development of
complications. The goal of the pyramid approach is to keep the base as large as possible
while aligning appropriate services at each level.

2.3
Population Focus

Guidelines
The organization has mechanisms in place to ensure the populations it serves can
provide input about the services they need.

2.4
Population Focus

The organization seeks input from the populations it serves to identify service
needs.

The organization targets high-risk and hard-to-reach cancer populations.


Guidelines
High-risk and hard-to-reach groups may include ethnic minorities and populations without
access to a primary care provider. Techniques to target these groups may include case
finding or screening and outreach to proactively reach clients who may benefit from the
organizations services.

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PARTNERING WITH THE COMMUNITY


3.0

The organization has partnerships with primary care, other organizations, and the
community to integrate services across the continuum of care for cancer
populations.
3.1

Guidelines
Partners may include primary care providers, community health organizations and
programs, cancer agencies, pharmacists, psychosocial programs and services including
volunteer programs, public health services, academic programs, and research institutions.
The organization collaborates with organizations outside the health sector where
possible.

Population Focus

3.2
Effectiveness

When developing partnerships in the community, the organization has a process


to assess the quality of services provided by the partner organization.
Guidelines
The process may include mechanisms to ensure the partner organization follows an
internal quality improvement process, tracks common indicators and measures of quality,
or shares results from external reviews such as audits or accreditation.

3.3
Population Focus

The organization seeks input from its partners to develop programs and policies
for populations with cancer.
Guidelines
The organization actively involves its partners when changing or redesigning services.

3.4
Accessibility

The organization collaborates with its partners to help clients access community
resources and the most appropriate services.
Guidelines
Access to services is coordinated inside the organization or health system, as well as
among primary care providers, community partners or agencies, and clients and families.
A central point of access may be used to improve coordination.

4.0

The organization collaborates with the community to prevent cancer and improve
cancer services.
4.1

Population Focus

The organization collaborates with its partners to create supportive environments


for populations with or at risk for cancer.
Guidelines
Supportive environments can include both living and employment conditions, such as
smoke-free work environments, linkages to smoking-cessation, nutritional, exercise or
other healthy living programs, and accessible transportation.

4.2
Population Focus

The organization develops partnerships with organizations in the community.

The organization encourages and participates in community action to promote


health, prevent disease, and support the community to manage its own health.
Guidelines
The organizations staff and service providers may act as leaders in the community to
promote health.
The organizations community initiatives address the needs and priorities of cancer
populations, social determinants of health, and risk factors for cancer. The organizations
health promotion and disease prevention strategies may be targeted to cancer in general,
or to specific types of cancer.
Where possible, the organization coordinates its efforts with community programs,
resources, or initiatives.

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4.3
Population Focus

The organization is knowledgeable about and advocates for healthy public policies
to prevent and reduce cancer.
Guidelines
Public policy mechanisms include taxation, legislation and fiscal policies. Healthy public
policies encourage individuals, companies, organizations and governments to make
healthy choices. Examples include the development and sharing of nutrition guidelines to
promote healthy eating, or supporting the development of legislation to ban smoking in
certain areas.
Depending on its size and resources, the organization may also be directly involved in
developing healthy public policies.

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INTEGRATING AND COORDINATING CANCER SERVICES


5.0

The organization uses an interdisciplinary approach to deliver its services for


cancer populations.
5.1

The organization identifies leaders who are responsible for coordinating the
interdisciplinary approach and all cancer services.

5.2

The organization identifies an interdisciplinary team based on the needs of the


populations it serves.

Effectiveness

Population Focus

Guidelines
The interdisciplinary team may include primary care providers; allied health professionals
including pharmacists; medical specialists such as oncologists, surgeons, pathology, and
radiology; case/care managers; volunteers; community partners including psychosocial
services; and administrators and management. Links with primary care providers outside
the organization who are largely responsible for care and services to clients with cancer
are particularly important.

5.3
Worklife

The organization encourages all team members to develop skills to improve the
interdisciplinary approach and overall team functioning.
Guidelines
Skills to improve interdisciplinary and team functioning may differ from required technical
skills; for example, cooperation and collaboration, communication, leadership, and
responsibility.

5.4
Effectiveness

The interdisciplinary team communicates regularly to coordinate services, roles,


and responsibilities.
Guidelines
Miscommunication or a lack of communication among interdisciplinary team members
often compromises client safety. Making accurate and timely communication a priority
promotes continuity of care and helps prevent adverse events.
Communication mechanisms can include meetings, teleconferences, or virtual
technologies such as telehealth or webconferencing, and may involve clients, families,
caregivers, or client advocates.

5.5
Effectiveness

The interdisciplinary team follows a formal process to regularly evaluate its


functioning, identify priorities for action, and make improvements.
Guidelines
The teams process to evaluate its functioning includes a review of its services,
processes, and outcomes. This could include administering a team functioning or climate
questionnaire to team members to stimulate discussion about areas for improvement.
The team evaluates its functioning at least annually, and whenever there is significant
change in the structure of the team.

6.0

The organization has clear roles and responsibilities for delivering services to
cancer populations.

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6.1
Worklife

The organization has position profiles and defined roles and responsibilities for
each staff and service provider involved in delivering services to populations with
cancer.
Guidelines
Defining roles and responsibilities includes making it clear who is responsible for the
various aspects of cancer management and services, including primary and secondary
prevention programs; diagnosis; treatment and service coordination; client, family and
caregiver education; facilitation of self-management; and follow-up, rehabilitation, and
palliation.
Staff and service providers have access to detailed position profiles to help them
understand their roles and responsibilities. Routines and duties for each profile are
documented to promote consistent care when different individuals perform the same
roles. The organization may also provide staff and service providers with tools such as
checklists to manage their different roles and responsibilities.

6.2
Worklife

The organization defines the team structure, including reporting relationships and
accountability for decision-making.
Guidelines
Reporting relationships and accountability for decision-making follow practice and
licensing restrictions and include all members of the interdisciplinary team, including
primary care providers.

6.3
Worklife

Staff and service providers have input on work and job design, including the
definition of roles and responsibilities, and case assignments where appropriate.
Guidelines
Job design refers to how a group of tasks, or an entire job, is organized. Job design
addresses all factors that affect the work, including job rotation, work breaks, and working
hours. Effective job design helps staff and service providers manage time, fatigue, stress,
and worklife balance.

6.4
Efficiency

Staff and service providers work to their full scope of practice when delivering
cancer services.
Guidelines
Full scope of practice means the organization makes the best use of each staff person
and service provider on the team. This may include increased roles for non-physicians in
delivering cancer services.

7.0

The interdisciplinary team coordinates services for populations with cancer.


7.1

Clients served by the organization know where and how to access services.
Guidelines
Information about the organizations services and the best way to access them is easily
available.

Accessibility

Clients are aware of who is responsible for coordinating their services and how to contact
that person if they have questions or need information. The organization may provide a
client navigator who helps clients access services inside or outside the organization.

7.2
Client-centred
Services

The interdisciplinary team coordinates services and follow-up for populations with
cancer.
Guidelines
Services emphasize health promotion and disease prevention and are consistent with
evidence-based guidelines. The organization may focus on promoting prevention and
early interventions for hard-to-reach populations (e.g. ethnic minorities, those without
access to a primary health care provider).
Methods for follow-up may include phone, in-person, e-mail or other methods to improve
client access and flow through the system.

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7.3

Guidelines
To reduce unnecessary visits, the organization tries to schedule appointments so clients,
particularly those requiring complex pain and symptom management, receiving
concurrent chemotherapy and radiation therapy, and needing to see multiple specialists
during follow-up can access multiple service providers or other services in a single visit.

Client-centred
Services

ROP
Continuity of
Services

The interdisciplinary team helps clients access multiple services in a single visit.

7.4

REQUIRED ORGANIZATIONAL PRACTICE: The interdisciplinary team transfers


information effectively among service providers at transition points.
Guidelines
Transition points include shift changes, end of service, and client movement between
health services and sectors. Effective transfer of information requires active coordination
and communication with primary care providers, particularly those working outside the
organization, to provide seamless services to clients and to determine the most
appropriate service setting.
Effective communication has been identified as a critical element in improving client
safety, particularly with regard to transferring clients to other client services teams, and
between hospital and community-based providers.

Test(s) for Compliance


7.4.1

The team uses mechanisms for timely transfer of information at


transition points (e.g. transfer forms, checklists) that result in proper
information transfer.

7.4.2

Staff is aware of the organizational mechanisms used to transfer


information.

7.4.3

There is documented evidence that timely transfer of information occurs.

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SUPPORTING CLIENTS TO SELF-MANAGE THEIR CARE AND SYMPTOMS


8.0

The organization works with community partners to support clients and families to
self-manage their condition, care, and symptoms.
8.1

Client-centred
Services

The organization identifies self-management as part of its services for clients with
cancer.
Guidelines
Self-management is an important component of living with cancer and its symptoms,
regardless of the diagnosis or its progression, helping clients to maintain or improve their
health and quality of life. Self-management skills assist clients to manage day-to-day
challenges of living with cancer, to actively participate in decisions about their health and
health services, and to maintain independence for as long as possible. Self-management
support programs may be delivered through a variety of approaches and can include goal
setting and problem solving; coping with physical and emotional symptoms such as
fatigue, pain, fear, and depression; diet and exercise; and ways to communicate
effectively with family, friends, and medical professionals.

8.2

The organization offers clients and families clinical education about cancer.
Guidelines
The education may focus on the risk factors common to many chronic conditions, or
provide information related to cancer in general, e.g. managing radiation side effects and
symptoms, or related to a specific type of cancer such as breast cancer.

Client-centred
Services

The education may be delivered by a clinical educator, a staff member or service


provider, or by peers. It may be delivered in person, virtually, by telephone conference or
webcast, or through other approaches such as written materials, help-lines, or websites.

8.3
Client-centred
Services

Guidelines
Service providers appropriately and consistently assess and document their clients need
for self-management support. They are aware of programs and information available
through the organization or in the community, such as behavioural change programs,
books, peer support, diet and exercise programs, or mentoring programs, and make
referrals as required.

8.4
Client-centred
Services

The organizations self-management programs focus on client empowerment and


problem-solving methodologies.
Guidelines
The goal of self-management is to enable clients to participate in managing their health
care needs and make informed decisions by providing them with appropriate tools and
information.

8.5
Client-centred
Services

The organization provides information to service providers so they can refer


clients to self-management programs.

The organizations self-management programs include support for families and


caregivers of those living with cancer.
Guidelines
The organization links families and caregivers to its own or community support groups
and mentoring programs, e.g. bereavement services for families of clients in the palliative
stages of cancer. Support groups and programs may be available in a variety of ways,
including virtual.

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BASING DECISIONS ON RESEARCH AND EVIDENCE


9.0

The organization provides staff and service providers with access to education and
training to improve services for cancer populations.
9.1

Accessibility

Staff and service providers have access to education and training activities
specific to cancer services.
Guidelines
The training may include a variety of tools and methods to support services for those with
cancer, such as the chronic disease management model and its application to cancer
services, population-based health management, client-centred services, and
self-management support. It may also include information about risk factors specific to
the populations served; social determinants of health; and strategies to promote health,
access services, and prevent disease or illness.

9.2
Effectiveness

The organizations cancer training includes information on evidence-based


guidelines.
Guidelines
The training addresses interpreting evidence-based guidelines, and information on how to
manage multiple recommendations from a variety of guidelines.

9.3
Worklife

The organization encourages and supports staff and service providers to pursue
ongoing education and professional development related to cancer and cancer
services.
Guidelines
Organizational support for education and professional development may include policies
or resources for attending conferences or symposiums, or resources or flexible work
hours to pursue educational opportunities. The organization is encouraged to track the
number of staff and service providers who undertake professional development activities.

9.4
Worklife

The organization supports student and volunteer placement in its cancer


programs.
Guidelines
If students or volunteers are placed with the organization, the organization provides
adequate resources and supervision, and evaluates the student or volunteer placements
regularly.

10.0 The organization bases its services for cancer populations on evidence-based
guidelines, research, and best practice.
10.1
Effectiveness

The organization has a process to select evidence-based guidelines for its cancer
services across the continuum of service.
Guidelines
Evidence-based guidelines may be established internally by a committee, a council, or an
individual who develops tools and makes recommendations to the team.
Guidelines from other organizations or associations may be adopted by the team. The
process for selecting guidelines is standardized and formalized. It may include using
content experts, a consensus panel, or the Appraisal of Guidelines Research and
Evaluation (AGREE) instrument, which allows organizations to evaluate the
methodological development of clinical practice guidelines from six perspectives: scope
and purpose, stakeholder involvement, rigour of development, clarity and presentation,
applicability, and editorial independence.
Comprehensive documents that synthesize the evidence from several guidelines are also
available. For example, the Cochrane Collaboration conducts systematic reviews of the
available evidence; this can help service providers and organizations with their review
process. Where synthesized information is not available, the organization has a process
to deal with and decide among conflicting guidelines or multiple recommendations.
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10.2
Accessibility

The organization makes information about evidence-based guidelines and how to


implement them available to staff and service providers.
Guidelines
The information may be the actual guidelines, or an applied version such as a clinical
pathway. The information that is provided also includes the organizations plans for
implementing the guidelines or pathways in its services, and for managing the impact on
services, roles, and responsibilities.

10.3
Effectiveness

The organization reviews its guidelines to make sure they are up-to-date and
reflect current research and best practice.
Guidelines
The organizations review includes ways to access the most up-to-date research and
information, e.g. through literature reviews, content experts, national organizations or
associations, or the Cochrane Collaboration. Research information may include
intervention research, program evaluations, and clinical trials.

10.4
Effectiveness

The organizations research activities for cancer services meet applicable


research and ethics protocols and standards.
Guidelines
The organization may participate in research initiatives to improve the quality of cancer
services, e.g. clinical trials, assessments of new interventions, or changes to existing
ones.
Research and ethics protocols and standards include those for client consent to
participate in research activities.

10.5

The organization shares benchmark and best practice information with its partners
and other organizations.

10.6

Staff and service providers share information about the evidence-based


guidelines, research, and best practice with clients and families.

Population Focus

Client-centred
Services

Guidelines
Brochures and other information about guidelines, research, and best practice that are
developed for clients and families are easy to understand.

11.0 Staff and service providers have access to specialist expertise to improve its cancer
services.
11.1
Accessibility

The organization provides staff and service providers, including primary care
providers, with access to specialist expertise to prevent, manage, and treat
cancer.
Guidelines
Access to specialist expertise builds capacity to better manage cancer services. Staff,
service providers, and primary care providers both inside and outside the organization
have access to cancer-specific expertise, or advice on managing cancer-related
symptoms such as complex pain or emotional distress.
Access may include virtual connections, involvement of specialists with primary care
teams, and innovative approaches to deliver services in the community.

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11.2
Effectiveness

Specialists provide leadership and consultation to improve services to cancer


populations.
Guidelines
Specialists can offer a unique perspective about the delivery of cancer services, and can
play a leading role in service improvement, redesign of services, and the development of
new initiatives for cancer services, e.g. the development and implementation of specialty
clinics.
Specialists can also provide input and consultation to the organization about how to
improve cancer services, e.g. how to integrate specialty services with the cancer services
program or primary care services, how to create incentives for specialists to become
more involved in the cancer services program, and how to improve access to
cancer-specific expertise for all service providers, including primary care providers.

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USING INFORMATION AND INFORMATION TECHNOLOGY


12.0 The organizations clinical information system provides accurate, timely, and useful
information.
12.1
Population Focus

The organization maintains a clinical information system and longitudinal client


records.
Guidelines
The information system may be called a client registry. It is not to be confused with
provincial cancer registries that have a regulatory obligation to collect provincial-level data
about cancer and specific diagnoses.
The organization has a minimum data set that specifies what is to be included in the
information system, as well as a minimum data set to standardize information collected
from clients.
The information system may be electronic (i.e. in a computer database) or on paper.
There is a growing movement toward electronic health records (EHR) or electronic
medical records (EMR) to increase access to and consistency of information across
multiple settings and service providers.
Client records include, at minimum, client name, diagnosis, contact information, and
documentation of all contacts with the organization.

12.2
Population Focus

Guidelines
The information system allows client information to be sorted by demographics, and by
type and stage of cancer to identify clinical priorities, triage, and manage wait lists.

12.3

Staff and service providers have timely access to clinical information.


Guidelines
The organization has policies outlining who may access client information, and how and
when they may do so. The organization also has a secure process to manage the flow of
information among staff, service providers, and other organizations.

Accessibility

12.4

Clients have opportunities to access their records.


Guidelines
Clients have the right to read and comment on information about them that is recorded by
the organization. In some cases, clients may be the primary holders of their health
information as they move across providers and settings; in others, they may be given
access to this information online.

Client-centred
Services

12.5
Effectiveness

The information system is used to establish clinical priorities by classifying clients


according to condition and other factors such as co-morbid conditions.

The organization has processes and procedures for maintaining the clinical
information system.
Guidelines
The processes and procedures address data collection, data entry, maintenance,
reporting, data and system security including back-up procedures, and training for staff
and service providers who use the system.

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12.6
Client-centred
Services

The organizations clinical information system meets legislation for protecting


client confidentiality.
Guidelines
Applicable legislation may include federal and provincial or territorial privacy regulations
and legislation, as well as legislation that applies to electronic health records (EHR) or
electronic medical records (EMR). At minimum, clients are informed if and when their
information is to be shared with other service providers, organizations, or bodies such as
a provincial cancer registry, and are provided with the opportunity to consent to the
sharing of their information.

12.7

The organization regularly reviews and improves its clinical information system.
Guidelines
For example, improving the clinical information system may include adding new data
fields.

Effectiveness

13.0 The organizations information system and technology support high quality,
coordinated services for populations with cancer.
13.1
Effectiveness

Guidelines
Evidence-based guidelines are embedded in the information system. The system
provides reminders and prompts to inform service providers when clients are in need of
services and follow-up, and to help the organization prioritize client needs and manage
the flow of clients through the system.

13.2
Client-centred
Services

During client appointments, the information system provides service providers with
information about adherence to applicable evidence-based guidelines and care
pathways.
Guidelines
The information allows staff and service providers to review whether the clients care,
treatment, and self-management goals are consistent with evidence-based guidelines and
care pathways.

13.3

Staff and service providers use the information system to schedule appointments.
Guidelines
The information system, whether electronic or otherwise, includes a reliable way to
identify and schedule appointments, and enables service providers to identify clients who
require or are overdue for follow-up. The information system may also permit clients to
schedule their own appointments and follow-up.

Effectiveness

13.4
Client-centred
Services

The information system is linked to evidence-based guidelines and provides


reminders that identify clients in need of services or follow-up.

The organization works with primary care providers, partners, and other
organizations to integrate information systems.
Guidelines
Where possible given applicable privacy legislation, integrating information systems
allows information to be shared among service providers, teams, service settings, and
organizations to improve coordination and avoid duplication. This is particularly important
between the organization and primary care providers.
The organizations information system also supports the organization in meeting reporting
requirements to provincial cancer registries.

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13.5
Effectiveness

The organization uses the information system to generate regular reports about
performance and adherence to guidelines, and to improve services and
processes.
Guidelines
Staff and service providers are provided with information on their adherence to
evidence-based guidelines, and team and clinical performance related to populations with
cancer. The organization may summarize the information by condition, risk factor, or other
variable.
The information can be used to improve the quality of services provided to cancer
populations, to drive cancer research, and to contribute to provincial or national
surveillance initiatives.

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MONITORING QUALITY AND ACHIEVING POSITIVE OUTCOMES


14.0 The organization promotes safety in its services for populations with cancer.
14.1
Safety

The organization trains staff and service providers to identify, reduce, and manage
risks to client or staff safety.
Guidelines
Staff and service providers feel comfortable identifying risks that may affect client or staff
safety, or their ability to deliver quality service. Risk management includes being aware of
issues that compromise the quality of service, and can include establishing and
maintaining contracts with community partners or others, maintaining safe and
appropriate equipment, proper training on the use of equipment, and knowledge of legal
liability.

14.2
Safety

Staff and service providers participate in regular safety briefings to share


information about potential safety problems, reduce the risk of error, and improve
the quality of service.
Guidelines
Regular opportunities to share information about potential problems and actual incidents
can reduce risk and the likelihood of an incident recurring.

14.3
Safety

Staff and service providers identify, report, record, and monitor in a timely way
sentinel events, near misses, and adverse events.
Guidelines
This includes investigating all incidents (e.g. sentinel events, near misses, and adverse
events), taking action to prevent the same situation from recurring, monitoring incidents,
and using lessons learned to make improvements.
This criterion is linked to the Required Organizational Practice in Accreditation Canadas
Standards for an Effective Organization that requires organizations to have a reporting
system consistent with applicable legislation for near misses, and sentinel and adverse
events.
Staff and service providers delivering cancer services are responsible for implementing
the organizations process. In addition, information about sentinel events, near misses
and adverse events is tracked for cancer services specifically and reported in a manner
consistent with others across the organization so the information may be summarized at
the organization level.

14.4
Safety

Staff and service providers follow the organizations policy and process to disclose
adverse events to clients and families.
Guidelines
This criterion is linked to the Required Organizational Practice in Accreditation Canadas
Standards for an Effective Organization that requires organizations to have a formal
process to disclose adverse events to clients and families.

15.0 The organization makes ongoing improvements to its services for cancer
populations.
15.1
Effectiveness

The organization identifies and monitors process and outcome measures for
cancer services.
Guidelines
The organization uses its quality improvement process to examine how services can be
improved and makes changes to achieve better results.
Process measures include adherence to evidence-based guidelines and provision of
self-management support. Outcome measures include readmission rates for certain
complications, composite indexes of quality of care or quality of life, and, population-,
cancer-type, or individual-specific clinical outcome measures.

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Qmentum Program

15.2
Client-centred
Services

The organization monitors clients and families perspectives on the quality of its
services for cancer populations.
Guidelines
The organization may seek client and family perspectives through surveys, focus groups,
interviews, or meetings.

15.3
Effectiveness

The organization compares its results with other similar interventions, programs,
or organizations.
Guidelines
The organization may participate in benchmarking opportunities and comparisons with
peer organizations to assess its performance and identify opportunities for improvement.
It also identifies and shares leading practices.

15.4
Effectiveness

The organization uses the information it collects about the quality of its services to
identify successes and opportunities for improvement, and makes improvements
in a timely way.
Guidelines
Ongoing quality improvement initiatives are part of a broader organizational philosophy of
quality improvement. The organizations efforts to monitor and improve the quality of its
services is integrated with the organizations overall work on quality improvement, risk
management and client safety, and utilization management, i.e. the efficient use of
resources.
Areas for improvement are prioritized based on defined criteria such as high risk, high
volume, and cost.

15.5
Population Focus

The organization shares its evaluation results with staff, clients, and families.
Guidelines
Sharing the results of evaluations and improvements helps staff become familiar with the
philosophy and benefits of quality improvement. It also increases clients and families
awareness of the organizations commitment to quality for its services for cancer
populations, and its commitment to ongoing quality improvement.

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