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American College of Surgeons: Cancer Programs

Commission on Cancer > Accreditation > Program Resources

Guidelines for Merged Cancer Programs

If your facility has merged, or plans to merge in the near future, the Commission on Cancer (CoC) requests that you first review the Guidelines for Merged Cancer Programs presented below. After reviewing the guidelines, please complete the Merger Notification Form (70K DOC) and submit it to Carol Woody via e-mail at cwoody@facs.org. Questions regarding the Guidelines for Merged Programs should also be directed to Carol Woody at the e-mail address provided.

The following topics are addressed within these guidelines:

Merger Checklist

The following checklist is provided to ensure a successful merger and smooth transition between your facility and the CoC.

Demographic Information

The following information is required and should be included on the Merger Notification Form:

  1. complete name, street address, city, state, zip code, phone number, and Web site address (URL) of merged facility
  2. complete name, street address, city, state, zip code, and Facility Identification Number (FIN) of each campus
  3. contact information (name, credentials, title, street address, city, state, zip code, phone number, fax number, and e-mail address) for the following individuals:

Definition

Forming a cancer program network is an option for programs, whereas becoming a merged facility is not optional, but a mandatory CoC process resulting from two or more facilities’ decision to consolidate their services.

Please refer to the Guidelines for Network Cancer Programs for additional requirements for network programs.

Cancer Program Identification

Following receipt of the Merger Notification Form, CoC staff will provide the cancer registrar with an e-mail confirming the new FIN, reference date, cancer program category, and accreditation award designation for the merged facility.

The assignment of the reference date will take into consideration the following:

One category of accreditation will be assigned to the merged facility by the CoC. The category assignment will take into consideration the following:

One accreditation award will be assigned to the merged facility by the CoC. The award assignment will take into consideration the following:

Cancer Program Activity

A single coordinated cancer program is to be established that involves all campuses of the merged facility. This must be in place by the time of the next CoC cancer program survey, except where noted. This includes the following:

Cancer Liaison Physician (CLP)

A single cancer liaison physician (CLP) should be appointed to serve the merged facility. In most cases, a CLP currently in place at one of the campuses will be selected to fill this role. Upon selection of a CLP, all remaining CLP appointments will be terminated.

Another option would be to select an entirely new CLP. If a new liaison is selected, complete the Cancer Liaison Physician Membership Application Form or contact Carolyn Jones at cjones@facs.org.

If the merged facility believes that it is necessary to appoint more than one CLP (most likely if facilities are separated geographically), please contact Carolyn Jones. The merged facility must submit rationale in writing in order to receive permission to maintain more than one CLP.

Cancer Registry Operations and Database Management

Mergers affect registry operations and registry case identification data items in different ways. CoC observes that many merged programs continue to use separate registry databases at each campus after merging, at least in the short term, while others combine all cases into a single registry database with new accession numbers assigned. When the registry data from multiple sources are being combined, the legacy (historic) FINs (NAACCR # 540) for the pre-existing registry data should be copied into the Archive FIN (NAACCR # 3100) area of the new combined registry so that the primary source of information is retained. The combined registry should have the assigned FIN for the merged program stored in the FIN (NAACCR item # 450) area.

Program access to CoC Datalinks and the NCDB data submission history or SAR standards 3.6, 3.7, and 3.8 histories will be accommodated through the new merger FIN once the merger has been approved. Prior to approval of the merger, access will be available only through the legacy FINs.

Previously accredited programs are required to submit NCDB data from the time of the merger reference date, in accord with the Calls for Data. Facilities (or campuses) that were not previously accredited are required to submit NCDB data from the date of the merger forward, but earlier cases may be submitted at the program’s discretion.

CoC Datalinks

CoC Datalinks is a central repository for maintaining CoC-accredited cancer program data and information. This password-protected portion of the CoC Web site enables programs to access, provide, and utilize facility-specific information. For purposes of the merger, the following CoC Datalinks portal applications are described in detail below. This list does not reflect all selections found within the application. Therefore, you are encouraged to access CoC Datalinks to view all selections.

Once facilities merge and notify the CoC of the newly selected chief executive officer/president/administrator, cancer program administrator, cancer committee chair, CLP, and cancer registrar, these contacts will be entered in the CoC's system under the newly assigned FIN. All previously assigned FINs will be deactivated and CoC Datalinks applications for the individual facilities will no longer be accessible. The merged facility will be responsible for submitting new facility and staff contact information, completing a new SAR and FIPS application, signing the HIPAA BAA, and submitting data to the NCDB as described above.

The designated cancer registrar, cancer committee chair, CLP, and cancer program administrator are automatically granted access to CoC Datalinks. If any of these staff had user IDs and passwords prior to the merger, their user IDs and passwords will remain the same and can be used to access the merged facility's CoC Datalinks applications. Those who were not identified as designated staff by the merged facility and were previously granted access to CoC Datalinks through the old FIN will no longer be authorized users.

If the merged facility assigns a new cancer registrar, cancer committee chair, CLP, or cancer program administrator who does not already have a CoC user ID and password, that individual will be assigned a unique user ID and password via e-mail to access CoC Datalinks. For security purposes and to protect facility data, user IDs and passwords are not to be shared. The CoC is not responsible for the unauthorized release or sharing of log-in information and data by any CoC Datalinks user.

A facility may request CoC Datalinks access for additional members of the cancer program and/or medical staff. These additional users must complete the CoC Datalinks User Request Form (345K PDF). It is at the discretion of the merged facility to designate the additional users and to notify the CoC of these users.

Facility and Staff Contact Information

Upon CoC accreditation of the merged program, the cancer registrar or designee must access the facility and staff contact information in CoC Datalinks and enter information for the facility and cancer program staff.

Health Insurance Portability and Accountability Act (HIPAA)

Under the HIPAA regulations, the American College of Surgeons (ACoS) serves as a "business associate" to assist you with accreditation and quality improvement efforts of your cancer program. To accomplish these tasks, the ACoS must enter into BAAs with all CoC-accredited cancer programs. Before any cancer program can schedule a survey, and before data can be accepted by the NCDB, a signed BAA must be in place. The merged facility can access the BAA to provide its electronic signature through the CoC Datalinks activity menu of the password-protected CoC Datalinks portal. Information describing the BAA is accessible through the HIPAA link at http://www.facs.org/cancer/coc/hipaa.html.

The BAA specifically addresses the following issues:

A BAA has been individually signed by each CoC-accredited facility involved in the merger. Facilities that are part of the merger but are not currently accredited by the CoC are not business associates of the ACoS and have not signed a BAA. Once the merged program receives confirmation of the merger by the CoC, the merged program must immediately access CoC Datalinks and sign the BAA. The merged facility must sign a new BAA, including the Security Amendment, before a survey of the merged facility can take place or data from the merged facility can be submitted to the NCDB. The merger will not be officially recognized by the CoC until this initial step is complete. The BAA currently in effect prior to the merger will remain in effect until a BAA for the merged facility is signed.

Facility Information Profile System (FIPS)

FIPS is a collaborative data-sharing project between the CoC and the American Cancer Society (ACS). It is a Web-based application in which CoC-accredited cancer programs provide information describing the resources and services they provide either on site or by referral to cancer patients and their families. These data are automatically shared with the ACS and through their National Cancer Information Center (NCIC) (1-800-ACS-2345).

Prior to merging, individual facilities accredited by the CoC are listed separately in FIPS Levels I and II. Following the merger, a single Level I record will appear that includes historical information from one of the original facilities. All resource and service information must be reviewed and updated to reflect the merged facility within 90 days of the CoC’s recognition of the merger. FIPS records for the individual facilities will be removed and the information for individual facilities will no longer be shared with the ACS.

Once the facilities have merged, Level II data, cases reported to the NCDB by site and stage, are posted to the merged facility's FIPS record as a cumulative report. The cancer registrar of the merged facility will receive an e-mail notification once this cumulative report is posted to FIPS, and the merged facility must determine whether they will authorize release of the cancer caseload data to the ACS within 90 days of the merger.

If you have any questions about the FIPS program, please contact FIPS@facs.org.

National Cancer Data Base (NCDB) Data Transmission

After the BAA has been signed and the merged program accredited, it is possible for the registrar to submit data to NCDB representing the merged program and to track the progress of NCDB data submissions under the new merger FIN through the “History and Edits of Patient-Level Data Submission to the NCDB” in the CoC Datalinks. Information for preparing and submitting data can be found at http://www.facs.org/cancer/ncdb/datasubmission.html. Contact NCDB staff at ncdb@facs.org if clarification of submission information is necessary.

NCDB Statistics

Newly merged programs will have access to the Survival Reports for the merged program once the merger is approved. However, the Hospital Comparison Benchmark Reports and Cancer Program Practice Profile Reports (CP3Rs) are updated annually and will become available for the merged program only after the next annual update, which takes place in the fall and is based on all data submitted through the preceding Call for Data submission period. Programs that anticipate needing the information from these tools in the interim should secure screen shots or images of the relevant information prior to approval of the merger. Extensive documentation for these tools is available within each application. See http://www.facs.org/cancer/ncdb/qualitytools.html for an overview of the NCDB statistical tools.

Survey Application Record (SAR)

Cancer programs participating in the CoC Accreditation Program are asked to complete the Survey Application Record (SAR) in preparation for the survey. The SAR details the cancer program's activity as it relates to compliance with the CoC’s standards as outlined in Cancer Program Standards 2009, Revised Edition.

The SAR Annual Update period is July 1 through September 30 each year for all programs not surveyed during that year.

To assist with completion of the SAR and SAR Annual Update, utilize the SAR Instruction Guide and the SAR Tips document that can be found at http://www.facs.org/cancer/coc/surveyresources.html. It is strongly recommended that the entire guide be reviewed before completing the application as the guide contains explanations and directions on how to complete the SAR and the SAR Annual Update.

Prior to merging, individual facilities accredited by the CoC are listed separately in separate SARs. Following the merger, a single SAR will appear that includes historical information from one or a combination of the original facilities. The merged program is responsible for updating and completing the SAR as requested at the time of the survey or during the annual update period.

For questions regarding the SAR and SAR Annual Update, e-mail SAR@facs.org.

 

Program Resources

 

 

Revised JOctober 18, 2011