Screening Centers of Excellence Application

 

Facility Information

Tell us about your program

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Question - Required - 3. Please indicate your current screening population/criteria: (please check all that apply)

 

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Question - Required - 4. Protocol used to guide technical specifications of screening exam and decision-making regarding finding: (please check all that apply)

 

 

Smoking Cessation

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Question - Required - 5. Smoking cessation resources used to refer screening patients who currently smoke: (please check all that apply)

 

 

Online Resources

 

 

Printed Resources

 

 

Other Resources

 

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Question - Required - 7. Does your program conduct any follow-up with your screening patients who currently smoke and who have been referred to cessation services, to gauge uptake/success?

 

 

Multidisciplinary team (MDT)

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Question - Required - 9. Which disciplines are a part of your MDT? (please check all that apply)

 

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Question - Required - 10. How frequently does your MDT meet?

 

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Question - Required - 11. What (if any) types of screening cases are discussed by the lung cancer multidisciplinary team (MDT)? ( please check all that apply)

 

 

Patient Education about Risks and Benefits

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Question - Required - 12. For Medicare beneficiaries, how do screening candidates receive the required counseling and shared decision-making visit? (please check all that apply)

 

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Question - Required - 14. For privately insured, do you still require a full counseling and shared decision-making visit?

 

 

Results Reporting

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Question - Required - 16. How are screening results reported to patients? (please check all that apply)

 

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Question - Required - 17. How are screening results reported to referring providers? (please check all that apply)

 

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Question - Required - 18. What is the reporting time frame to inform patients/providers about significant positive findings (such as a LungRADS 4 or other urgent incidental finding)?

 

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Question - Required - 19. What is the reporting time frame to inform patients/providers about negative or non-significant findings (such as nodules not needing immediate follow up or less urgent incidental findings)?

 

 

ACR Lung Cancer Screening Designation

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Question - Required - 20. Has your program applied for or received the ACR Lung Cancer Screening Center designation?

 

 

Attestation

A Screening Center of Excellence will:

  • Provide clear information on the risks and benefits of LDCT screening through a shared decision-making process. 
  • Comply with standards based on best published practices for controlling screening quality, radiation dose and diagnostic procedures. 
  • Work with or ensure a referral process to a lung cancer multidisciplinary clinical team, including radiologist, pathologists, pulmonologists, thoracic surgeons, oncologists, radiation oncologists and nurses to carry out a coordinated process for screening, follow up and treatment when appropriate.
  • Include a comprehensive cessation program for those still smoking or referral to comprehensive cessation programs.
  • Report results to those screened and their primary care doctors and transmit requested copies in a timely manner. 
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Contact information for main point of contact at facility: (if different from applicant)

 


   


   


   


   


   


 


 

Facility Information

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Once you have submitted your application, you will have an opportunity on the next page to add additional facilities/locations that follow the same criteria and protocols if you wish to do so.

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