If your facility has, is, or plans to merge in the near future, the Commission on Cancer (CoC) would like you to review the Guidelines for Merged Programs presented below. After review of the Guidelines, please complete the Merger Notification Form (MS Word File) and submit it to Carol Woody, Administrative Assistant for Approvals and Standards, via e-mail at cwoody@facs.org. Questions regarding these Guidelines for Merged Programs should be directed to Carol Woody at the e-mail address provided.

The following topics are addressed within these guidelines:

• Demographic Information
• Definition
• Cancer Program Identification
• Cancer Program Activity
• Cancer Liaison Physician
• Cancer Registry Operations and Database Management
• CoC Datalinks
• Merger Checklist
• Merger Notification Form

Demographic Information

The following information is required:

1. Complete name of merged facility, street address, city, state, Zip code, phone number, and Web site address (URL).
2. Complete name of each campus, Facility Identification Number (FIN), city, and state.
3. Contact information (name, credentials, title, street address, city, state, Zip code, phone number, fax number, and e-mail address) for the following individuals:
   CEO/President/Administrator
   Cancer program director/Administrator
   Cancer committee chair
   Cancer liaison physician
   Cancer registrar
   
   (The selection of these contacts is left to the discretion of the merged facility.)

Definition

• A merged facility is composed of two or more campuses with a single accreditation standing from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the American Osteopathic Association (AOA), or a health facility licensor organization (usually located within the State Health Department).
• The merged facility will have one cancer program, effective with the date of the merger. All cancer program activities of the campuses in the merger must begin to work together even if the medical staff has not yet merged and activities have not yet been consolidated.
• Difference between "network" and "merged programs:"
  • Network: Each hospital is individually operated and accredited, but all are owned by the same parent company.
  • Merged: One hospital now owns another hospital. They become one hospital with multiple campuses and are operated and accredited as one facility.
  • Forming a network is an option for programs, whereas becoming a merged facility is not optional.
    
    Please refer to the Guidelines for Network Cancer Programs on our web site for additional requirements for network programs.

Cancer Program Identification

CoC Cancer Programs Staff will provide the cancer registrar with an e-mail confirming the new Facility Identification Number (FIN), reference date, cancer program category, and approval award designation for the merged facility. The FIN's for the existing individual campuses are made inactive in the CoC Cancer Programs database.

The assignment of the reference date will take into consideration:

• current CoC guidelines on reference dates
• current status (approved or not approved) of the individual campuses
• the earliest reference date of the individual campuses

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

• the categories of the individual campuses
• the scope of services provided at all campuses
• the number of annual analytic accessions at all campuses

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

• the current status (approved or not approved) of the individual campuses (campuses not approved prior to the merger become approved upon merger)
• the outstanding deficiencies, if any exist, for the individual campuses

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 program survey, except where noted. This includes:

• a coordinated approach to the provision of clinical services involving all campuses of the merged facility
• a single cancer committee representing the cancer activities and medical staff at all campuses (campus-based subcommittees may be established as long as the subcommittee activity is reported to the cancer committee)
• a single program of cancer conferences representing the case mix of the merged facility
• a single system of studies of quality and improvements in cancer patient care addressing issues at all campuses of the merged facility
• an overall program for clinical research at the merged facility, if applicable
• one system for supportive services and community outreach through screening and early detection programs coordinated among all campuses of the merged facility
• an overall program for professional education and staff support within the merged facility.

Cancer Liaison Physician (CLP)

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

Another option would be to select an entirely new cancer liaison physician. If a new liaison is selected, complete the Cancer Liaison Physician Membership Application Form available at http://www.facs.org/cancer/coc/liaison.html or contact Carolyn Jones, Cancer Liaison Program Coordinator, at cjones@facs.org.

If the merged facility feels that it is necessary to appoint more than one cancer liaison physician (most likely if multiple campuses exist), please contact Carolyn Jones. The merged facility must submit rationale in writing in order to receive permission to maintain more than one cancer liaison physician.

Cancer Registry Operations and Database Management

The cancer registry data from each applicable facility must be merged. This should resolve the requests for survey delay. For the purpose of survey, all new case accessions and case follow-up activity must be managed using the merged database. Merged facilities will be required to combine their existing data sets from each respective campus and maintain follow-up activities for all cases within 12 months of the merger being recognized by the CoC. Programs should work closely with their registry software providers during this process to ensure a successful transition. For the purpose of survey, all new case accessions and case follow-up activity must be managed using the merged database.

The following steps will be required to ensure that all cases in the new registry remain uniquely identified.

Facility Identification Numbers (FIN) for mergers completed after January 1, 2003:

The FIN number (NAACCR item #540) which was unique to each respective registry prior to the merger is copied into the data item "Archive FIN" (NAACCR item #3100).

For facilities with a seven-digit FIN in the range of 6020009-6953290 that were assigned by the CoC before January 1, 2001, the Archive FIN will consist of three leading zeros followed by the full seven-digit FIN of the merging registry. For facilities with an eight-digit FIN greater than or equal to 10000000 that were assigned by the CoC after January 1, 2001, the Archive FIN will consist of two leading zeros followed by the full eight-digit FIN of the merging registry.

The FIN number assigned by the CoC to identify the new merged facility is assigned to all cases present in each respective registry's data set. This assignment will overwrite the FIN number that was unique to each registry prior to the merger. Merge the data from each registry into one, single data set.

Example: South Central Community Hospital (FIN number 18888888) and Jefferson Memorial FIN number 6008888 merge to form Jefferson Community Hospitals. The newly merged facility is assigned a new FIN number, 17777777, by the CoC. The FIN number of all the cases in each of the respective registries, South Central Community (18888888) and Jefferson Memorial (6008888), are copied into the item Archive FIN. The FIN number of all the cases in the registries at South Central Community and Jefferson Memorial are re-coded to the new FIN number, 1777777. The data from the two registries can then be combined. The combination of new merger FIN number, the Archive FIN, and the original accession numbers allows cases to remain uniquely identifiable in the combined data set.

CoC Datalinks

CoC Datalinks is a central repository for maintaining CoC-approved 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.

• Facility and Staff Contact Information
• HIPAA Business Associate Agreement
• Facility Information Profile System (FIPS)
• National Cancer Data Base (NCDB)
• Survey Application Record (SAR)

Once facilities merge and notify the CoC of the newly selected CEO/President/Administrator, Cancer program director/Administrator, Cancer committee chair, Cancer liaison physician, cancer registrar, these contacts will be entered in the CoC's system under the newly assigned FIN. All previously assigned FINs will be inactivated and CoC Datalinks applications for the individual facilities will no longer be accessible. All data submitted and completed prior to the merger will be archived, and the merged facility will be responsible for submitting new Facility and Staff Contact Information and for completing a new SAR, FIPS application, signing the HIPAA Business Associate Agreement, and submitting data to the NCDB as one facility.

Upon CoC approval of the merged facility, the Cancer registrar, Cancer committee chair, Cancer liaison physician, and Cancer program administrator will automatically be granted access to CoC Datalinks. User IDs and passwords of these designated staff remain the same from previous assignments and can be used to access the merged facility's CoC Datalinks applications. Those that were not selected as designated staff by the merged facility and were previously granted access to CoC Datalinks through their old FIN, will no longer be authorized users.

If the merged facility assigns a new Cancer registrar, Cancer committee chair, Cancer liaison physician, or Cancer program administrator, and the staff never previously had access to CoC Datalinks, a unique User ID and password will be assigned and e-mailed to the new user. 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 login information and data by any CoC Datalinks user.

A facility may request access for up to six additional members of the cancer program and/or medical staff. If any of these additional users were previously assigned a User ID and password, these will remain the same. However, if any of these additional users are new users of CoC Datalinks, they must complete the "Request for an Additional User" form, located on the CoC Web site at http://www.facs.org/cancer/index.html. It is at the discretion of the merged facility to designate the six additional users and to notify the CoC of these users.

Facility and Staff Contact Information
Upon CoC approval of the merged facility, 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 (BA)" to assist you with approvals and quality improvement efforts for your cancer program. To accomplish these tasks, we must enter into Business Associate (BA) Agreements with all CoC-approved cancer programs. Before any cancer program can schedule a survey, and before data can be accepted by the NCDB, a signed BA Agreement must be in place. The merged facility accesses the BA Agreement for electronic signature through the Activity Menu of the password-protected CoC Datalinks portal.

The BA Agreement specifically addresses the following issues:

• data confidentiality
• systems in place to safeguard protected health information within the CoC's NCDB
• the survey process and surveyors associated with the Approvals Program

A BA Agreement has been individually signed by each CoC-approved facility involved in the merger. Facilities that are part of the merger, but not currently approved by the CoC are not Business Associates of the ACoS and have not signed a BA Agreement.

Information describing the BA Agreement is accessible through the HIPAA link found on the Cancer Programs page of the Web site. Once the merged program receives confirmation of the merger by the CoC, the merged program must immediately access CoC Datalinks and sign the BA Agreement. The merged facility must sign a new BA Agreement 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. BA Agreements currently in effect will remain in effect until a BA Agreement for the merged facility is signed. The merger will not be officially recognized by the CoC until this initial step is complete.

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-approved 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 on their Web site at http://www.cancer.org, and through their National Cancer Information Center (NCIC) (1-800-ACS-2345).

Prior to merging, individual campuses approved by the CoC would have been listed separately in FIPS and cancer program staff at the individual campuses would have been given access to update campus-specific service information. However, following the merger, a single record for the merged facility including the facility name and facility identification number (FIN) will be added to the FIPS system. This record will appear blank. All resource and service information must be completed and updated to reflect the merged facility within 90 days of the merger. FIPS records for the individual facilities will be removed when the FINs are made inactive and the information for individual facilities will no longer be shared with the ACS.

Once a facility is merged, Level II data, or 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. Regardless of whether the individual campuses chose to release or not release Level II data in previous years prior to merger, it is necessary that the merged facility indicate its decision to share the caseload data with the ACS in FIPS.

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

National Cancer Data Base (NCDB) Data Transmission
Once facilities merge, they are required to submit their data to the NCDB using the new FIN. Data submissions using previous or individual FINs will not be accepted (see Cancer Registry Operations and Database Management above). Facilities that were not previously approved are required to submit NCDB data from the date of the merger forward.

NCDB Data Submission History and SAR Standards 3.6, 3.7, and 3.8 will display the NCDB data submission history and CoC special study participation of all individual facilities prior to their merger and the submission history of the merged facility.

Example: Following the merger of South Central Community Hospital and Jefferson Memorial into Jefferson Community Hospitals, the NCDB data submissions and special study participation will be displayed for all three entities under Jefferson Community Hospitals.

All the information for submitting data can be found on the NCDB Web page at http://www.facs.org/cancer/ncdb/registrars.html. Facility staff should contact Nancy Etzold via e-mail at netzold@facs.org, if clarification of submission guidelines is necessary.

NCDB Statistics
All CoC Datalinks users from the merged facility will be able to generate the same sets of reports that were available prior to the merger once an annual update process has been completed by the CoC. The information displayed in these reports is updated on an annual basis, and the combined data—reflecting the merged facility—will only appear once the annual update is complete. Help screens are available within the report applications, and tips sheets for using the reports, are available within the applications located on the NCDB Web page at http://www.facs.org/cancer/ncdb/ncdb.html.

Survey Application Record (SAR)
Cancer programs participating in the CoC Approvals Program are asked to complete the Survey Application Record (SAR) in preparation for survey. The SAR details the cancer program's activity as it relates to compliance with the CoC's Cancer Program Standards 2004.

• The designated cancer program staff is notified by e-mail when the SAR is available for Survey preparation or Annual Update completion.
• For programs due for survey, the SAR is available from November of the year prior to survey until 72 hours following the date of the survey.
• On an annual basis, programs are required to update certain sections of the application.

The SAR Annual Update period is July 1 through September 30 each year.

To assist with completion of the SAR and SAR Annual Update, the SAR Training Guide is located on the CoC Web site at http://www.facs.org/cancer/coc/sarguide.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.

Once the CoC has been notified of the merger and a new FIN has been assigned, the individual facilities will no longer be able to access the SAR under the previous FINs. All data included in the SAR prior to the merger is archived, and the merged program is responsible for completing a new SAR as requested at the time of the Survey or the Annual Update. Information from the previous facilities will not be copied over into the merged facilities new SAR. If you complete the FIPS application prior to the SAR, (FIPS will be accessible once the new FIN has been assigned), the completed FIPS pages will automatically copy over and appear in the SAR.

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

Merger Checklist

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

• Download Merger Notification Form.
• Determine Cancer Liaison Physician and indicate on Merger Notification Form.
• E-mail the completed Merger Notification Form to cwoody@facs.org.
• Receive confirmation from CoC (FIN, reference date, category, approval award).
• Share copy of completed Merger Notification Form and CoC confirmation with appropriate cancer program staff.
• Access CoC Datalinks with User ID and Password to review applications for new FIN:
  • Review and sign HIPAA Business Agreement
  • Update Facility and Staff Contact Information
  • Complete Facility Information Profile (FIPS) Application
  • View other applications reflecting the merger:
    • NCDB Data Transmission including History and Edits of Data Submitted to the NCDB
    • NCDB Statistics including Benchmark Reports and Cancer Program Practice Profile Reports
    • Survey Application Record (SAR)
• Merge cancer registry data in preparation for next NCDB Call for Data and CoC Survey.

Merger Notification Form (65K DOC)

  

Revised February 7, 2007

 

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