When a cancer program considers whether the pursuit of the Commission on Cancer (CoC) program accreditation is an attainable goal, the questions on the topic seem to come at an overwhelming pace. Must we hire more staff? Where will we find a patient navigator? How will we provide all the new services required? While it may seem as though there is too much to grapple with, there is a path to pursuing cancer program accreditation lying just under the surface of the sea of confusion.
Making the decision to seek CoC accreditation signals a cancer program’s desire to become a valued partner in the health of the community it serves; providing the highest quality cancer care and allowing patients to seek that kind of care close to home. The decision to pursue the path to accreditation should involve the facility or program administration – whether that is the board of directors, medical staff or task force – and include their review and understanding of the CoC standards. Understanding the commitment and timeline involved is crucial to the successful outcome of this pursuit.
Once the decision to go forward has been made, cancer committee takes the lead. Preliminary steps are:
- Form a cancer committee, if one is not in place. Use the latest version of CoC standards to guide the membership and meeting schedules. Accurate and complete cancer committee minutes are important in meeting requirements for accreditation. Keep in mind that a first survey will require submission of three years of cancer committee minutes.
- Appoint a cancer liaison physician, which should be a well thought-out choice. This physician will be the champion for the program. The standard addressing the specific duties will provide guidance for this choice.
- Establish a cancer registry. The cancer registry is one of the most important components for an accredited cancer program. In fact, the CoC considers it central to the accreditation process. It is not necessary that a program have a registry on-site. This function can be contracted but must be in compliance with CoC standards. In order to quality for an initial survey, the cancer program must document two years of abstracted data and one year of successful patient follow-up using the CoC standards and coding instructions in describing all reportable cases.
- Review, discuss, and understand the 12 Eligibility Requirements as described in the CoC Program Standards. These requirements address the basic structure and services that comprise an accredited program.
- Complete and submit a New Program Information Form to the CoC. By submitting this information, the program is advising the CoC that there is an interest in pursuing accreditation. This also allows cancer programs to receive important communication from the CoC which will assist the program in its work. It does not commit the program in any way and there is no fee for submitting this form.
Once these initial steps are in place, the members of cancer committee should begin using the latest version of the CoC Cancer Program Standards to build and improve the cancer program. Quality and data studies are identified and implemented using the specific standards. All disciplines providing care for cancer patients can and should participate in identifying quality and patient improvement studies within their departments. This is an ongoing task in a progressive cancer program.
Understanding, and keeping in mind, the benefits of becoming a CoC-accredited cancer program will serve all members of cancer committee, the facility administration, and all departments providing cancer care, well as work to achieve this goal moves forward. It is nationally recognized that CoC-accredited programs have established performance measures for the provision of high-quality cancer care. A program can participate in the National Cancer Data Base (NCDB) and have access to comparison benchmark reports and other resource tools made available to accredited programs. This data can be used to continually monitor and improve the level of cancer care. The public becomes aware of a program’s designation through CoC marketing, and the CoC Hospital Locator. Certain payers monitor the CoC site to determine which facilities offer the high level care associated with accreditation and use that information in contracting efforts.
The patient and community benefit when there is a CoC-accredited cancer program available to them. They learn that a comprehensive range of state-of-the-art services, a multidisciplinary team, the best treatment options, access to prevention and detection programs, and other support services are close to home. In addition, they will have the opportunity to participate in clinical trials and know that there is ongoing monitoring and improvements in cancer care.
Many cancer programs have been pleasantly surprised to find that they already meet some or many of the standards. The task then becomes formalizing policies or procedures per the standard language, identifying and documenting needed improvements in the cancer committee minutes, and then documenting the work and outcomes.
There are two important points to remember when working toward achieving CoC cancer program accreditation. The first is this: the CoC does not tell programs HOW to meet the standards. At first this may seem counterproductive, but it isn’t. The CoC recognizes that cancer programs vary widely as to size, staff, resources, geographic areas they serve (rural vs. urban), and number of patients seen. Cancer programs can meet the standard in any way that “works” for them. It should be noted that many of the services on which cancer programs are surveyed can be “on-site or by referral”. This allows for programs too small to have an on-site radiation facility, for example, to refer their patients for treatment with the caveat that the referral program meets the CoC standards for that service.
The second point refers to the definition of a “cancer program”. This applies to the structure and services provided, not a building, per se. There is no requirement for a cancer center building or specialized department within a facility. Although many programs desire a separate cancer center per se, no initial or future investment of this type is required in order to attain or maintain cancer program accreditation. Many facilities have a fully functional CoC-accredited cancer program in which various services are spread over a campus or are referred to providers within a community or region.
There will be times when the interpretation of a standard is not as clear as it could be. When a program faces a barrier to compliance or needs assistance in understanding what the CoC is looking for at survey time, contacting our CoC-trained consultant, Ms. Brutico, can be of benefit. Ms. Brutico is experienced in interpreting the standards, identifying quality and improvement projects, and reaching solutions for cancer programs. Working with programs can involve short-term or long-term projects and most work is accomplished without traveling to your site. The required consultative visit prior to an actual survey – for programs seeking their first survey – is one of our services, as well.
Achieving CoC Cancer Program Accreditation will take time and a clear commitment. Contact Pathway Cancer Program Consulting today at (775) 315-2320 to discuss how we can assist you in reaching your goal of CoC Cancer Program Accreditation.