The American College of Surgeons Commission on Cancer: Guidelines For Network Cancer Programs

If your facility plans to form a network with at least two or more hospitals, the Commission on Cancer (CoC) asks that you review the Guidelines for Network Cancer Programs presented below.

To start the process:

Contact Vicki Chiappetta by phone at 312/202-5288 or e-mail at Vchiappetta@facs.org to determine if your facilities are eligible to become a network.
Complete the Network Notification Form below once verification has been set and the network cancer program has been established by the facilities involved. The form can be found at http://www.facs.org/cancer/coc/guidelinesnetwork.html.
Have the network cancer committee chair or administrator draft a letter requesting the category change.
Submit the letter along with the completed Network Notification form to: Vicki Chiappetta, Technical Specialist, American College of Surgeons, 633 North Saint Clair Street, Chicago, IL 60611.

The following topics are addressed within these guidelines:

Definition and Eligibility Criteria
Cancer Program Identification
Network Processing: Cancer Liaison Physician; Reference Date; Network Consultation; Cancer Registry Operations and Database; Management

Preparing for Initial Survey: CoC Datalinks; Facility and Staff Contact Information; Health Insurance Portability and Accountability Act (HIPAA); Facility Information Profile System (FIPS); National Cancer Data Base (NCDB) Transmission; NCDB Statistics; Survey Application Record (SAR)

Definition and Eligibility Criteria

A network cancer program consists of individually operated hospitals (at least two) that are all owned by the same entity or corporation. There is one Board of Directors at the network level.
The network cancer program provides integrated cancer care and offers comprehensive services.
Each facility must be accredited by one or more of the following:
- The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
- American Osteopathic Association (AOA)
- Health facility licensure organization (usually located within the State Health Department)
Networks are characterized by:
- a network-wide cancer committee or functional equivalent
- standardized cancer registry operations with a uniform data repository
- coordinated service locations and practitioners within the network
- required participation in clinical research
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, where as becoming a merged facility is not optional.

Please refer to the Cancer Program Standards 2004, Revised Edition manual for additional requirements for network programs.

Cancer Program Identification

CoC Cancer Programs Staff will provide the network cancer committee chair, cancer liaison physician, cancer program administrator, and cancer registrar with an email confirming the network along with a new Facility Identification Number (FIN). (Until the network has a formal survey and receives full approval, the individual facilities will maintain their current CoC FINs, approval status, and cancer program category.)

Network Processing

Cancer Liaison Physician (CLP)

A cancer liaison physician must be appointed to serve the network. In most cases, a cancer liaison physician currently in place at one of the network’s individual facilities will be selected to fill this role. Another option would be to select an entirely new CLP. If a new liaison is selected, complete the Cancer Liaison Physician Membership Application Form available online or contact Carolyn Jones, Cancer Liaison Program Coordinator, at cjones@facs.org.

If the network feels that it is necessary to appoint more than one cancer liaison physician (one at each facility), please contact Carolyn Jones. The network must submit rationale in writing in order to receive permission to maintain more than one cancer liaison physician.

Reference Date

It is recommended that an existing reference date from one of the approved programs within the network be selected as the network reference date. A new reference date for the network registry does not need to be approved by the CoC.

If it is decided that a new reference date will be created, the facilities within the network must also change their existing reference dates to match that of the network. Requests to change the individual facilities’ reference date (to match the network reference date) must have prior approval from the cancer committee or functional equivalent.

The date change request should be submitted electronically to Lisa Landvogt, Administrator, Approvals and Standards or by fax at 312-202-5009. The Request to Change Reference Year Form should be used.

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 facilities
the earliest reference date of the approved individual facilities.

The reference date change for the individual approved programs will be communicated to the cancer registrar via email.

Network Consultation

The Cancer Program Standards 2004, Revised Edition for network programs must be in place for at least one year prior to the required network consultative visit. The cancer program will work with Vicki Chiappetta to coordinate the network consult. Once a date for consultation has been established, the network cancer registrar will be provided temporary access to the Consult Application Record (CAR) for consult preparation. The CAR is a stand alone application that is only available during the consult process. The information is not copied over to the Survey Application Record (SAR) for survey preparation. There is a flat fee for the consultation that is set by the CoC. Depending on the number of facilities included within the network, the consult visit will be at least one and a half days and will cover the following areas:

meeting with the network cancer program team
review of CAR
review of documentation to support compliance with the network standards
review of charts and abstracts from each facility
review of pathology reports from each facility
attendance at a cancer conference
tour of two facilities
summation with network cancer program team.

All network programs preparing for an initial network survey are considered “new” programs by the CoC and must meet all standards as outlined in Cancer Program Standards 2004, Revised Edition to receive full approval.

Cancer Registry Operations and Database Management

The network is required to combine the existing data sets from each individual facility and maintain follow-up activities for all cases within 12 months of the formal network formation. 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 network registry.

Preparing for Initial Survey

Once the network consultation has taken place and the program has been cleared for the initial network survey, the following applications become available; some of which require attention and action:

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 network, the following CoC Datalinks portal applications are described 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)

Until the network has a formal survey and receives full CoC Approval, the individual facilities currently approved by the CoC will maintain access to their CoC Datalinks applications (FIPS, NCDB, and SAR). User IDs and passwords of users at these individual facilities will not change. Upon network approval, all previously assigned FINs are inactivated, and CoC Datalinks applications for the individual facilities are no longer accessible. All data submitted and completed prior to the network approval is archived, and the network is responsible for signing the HIPAA Business Associate Agreement (BAA), submitting new facility and staff contact information, and completing a new SAR and FIPS application.

The designated network cancer registrar, network cancer committee chair, network cancer liaison physician, and network cancer program administrator are automatically granted access to CoC Datalinks. If any of these staff were in the same role prior to approval, their User IDs and passwords will remain the same and can be used to access the network’s CoC Datalinks applications. Those who were not selected as designated staff by the network facility and were previously granted access to CoC Datalinks through their old FIN will no longer be authorized users.

If the network assigns a new cancer registrar, cancer committee chair, cancer liaison physician, or cancer program administrator, who have never had access to CoC Datalinks, a unique User ID and password will be assigned via e-mail. 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 CoC Datalinks User” form, located on the CoC Web site at http://www.facs.org/cancer/coc/coc_add_user.pdf. It is at the discretion of the network to designate who the additional users are and notify the CoC.

Facility and Staff Contact Information

Upon CoC survey release of the network, the cancer registrar or designee must access the Facility and Staff Contact Information section within CoC Datalinks and enter information for the network 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 must be in place.

The BAA 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 Network. Each Network must sign a new BA Agreement including the Security Amendment before the network data can be submitted to the NCDB and a Network survey can take place. BA Agreements currently in effect will remain in effect until a Network BA is signed. Facilities that are part of the Network, but not currently approved by the CoC, are not considered Business Associates of the ACoS. These facilities must sign a BA Agreement once the network consult has taken place and the network program has been released for survey.

Following assignment of the network FIN, the consultative evaluation of network program activity, and release for survey, the network status is changed to PENDING which gives the cancer registrar access to CoC Datalinks to sign the BA Agreement.

Information describing the BA Agreement is accessible through the HIPAA link found on the American College of Surgeons Web site at https://web.facs.org/NCIC/NCDB_Contact_Info.cfm. The network program accesses the BA for electronic signature through the Activity Menu of the password-protected CoC Datalinks portal.

Once the network program has gone through the network consultation and the consult summary is received, the network and any non-approved facilities within the network must immediately access CoC Datalinks and sign the BA Agreement. The network survey will not be formally scheduled until all appropriate BA’s are signed and NCDB data submission by the non-approved facilities has been completed.

Facility Information Profile System (FIPS)

The Facility Information Profile System (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 joining as a network, individual facilities previously approved by the CoC are listed separately in FIPS. Following network approval, a single blank record will appear. All resource and service information must be completed and updated within 90 days of becoming a network. FIPS records for the individual facilities will be removed when the FINs become inactive and the information for individual facilities will no longer be shared with the ACS.

Following network approval, Level II data, or cases reported to the NCDB by site and stage, are posted to the network’s FIPS record as a cumulative report. The cancer registrar of the network will receive an e-mail notification once this cumulative report is posted to FIPS, and the network 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 becoming a network, it is necessary that the network indicate their decision to share the caseload data with the ACS in FIPS.

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

National Cancer Data Base (NCDB) Transmission

The individual approved facilities will still be required to submit their NCDB data under their individual FINs until the affected programs have received approval as a network cancer program. Facilities that were not previously approved are required to submit NCDB data from the most current year from the Last Annual Call for Data. Data submission is to be done before the network survey can take place. Once the network approval has been awarded, all individual FINs will be inactivated by the CoC and data transmission to the NCDB should utilize the network FIN from this point 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 the individual facilities prior to the network approval and the submission history of the network, once the program is awarded approval status as a network.

Example: Following the network formation of CoC Community Hospital and CoC Memorial Hospital into CoC Health System, NCDB data submissions will be displayed for all three entities under the CoC Health System network FIN. During the initial network survey the tables for Standards 3.6, 3.7, and 3.8 will be blank, information will be displayed in these SAR tables after network approval has been received. It is recommended that in preparation for the initial network survey, the registrar print copies of the data submission tables for the individual facilities from the ‘History and Edits of Patient Level Data Submission to the NCDB’ for the surveyor to review.

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 email at netzold@facs.org if clarification of submission guidelines is necessary.

NCDB Statistics

All CoC Datalinks users from the network program will be able to generate the same sets of reports that were available prior to the network formation 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 previously individual approved facilities - will only appear once the update is complete. Help screens are available within the report and tips sheets for using the reports are available located on the NCDB web page at http://www.facs.org/cancer/ncdb/index.html.

Survey Application Record (SAR)

Cancer programs participating in the CoC Approvals Program are required 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, Revised Edition.

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 until three business days 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 for all programs not surveyed during that 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.

Once the new FIN has been assigned to the network, the individual approved facilities will still be able to access all of their CoC Datalinks applications under the old FINs until network approval has been achieved. When preparing for initial survey, the network program is responsible for completing a new SAR under the new FIN. Information from the individual facilities’ SAR will not be copied over into the network SAR.

Once the network receives full approval, the individual facilities’ FINs, approval status, and cancer program category will be made inactive in the CoC Cancer Program Database and the new network FIN and network category will remain active. All data included in the individual programs’ SAR will be archived. The network FIN will be the only one recognized by the CoC once full network approval is achieved. All facilities within the network will receive a certificate of approval once the network survey has taken place and all standards have been met.

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

Network Checklist

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

Download Network Notification Form
Identify network Cancer Liaison Physician(s) and notify Carolyn Jones and indicate on Network Notification Form
Combine cancer registry data in preparation for network registry operations and CoC standard compliance.
Determine reference date for network program. We recommend you use an existing reference year from one of the approved programs within the network. If changing reference year for individual approved programs to match the network’s reference year, complete the Reference Date Change Request Form.
Mail network request letter along with the completed Network Notification Form to Vicki Chiappetta, Technical Specialist.
Receive confirmation from CoC with new FIN and category.
Share copy of completed Network Notification Form and CoC confirmation with appropriate cancer program staff.
Determine network consult date with Vicki Chiappetta at the CoC and access to the Consult Application Record (CAR) will be provided to the network registrar.
Work with the network cancer committee to complete CAR for consult preparation.
When network program is scheduled for initial network survey, CoC Datalinks access will become available to review applications under new FIN:
- Review and sign HIPAA Business Associate Agreement for network and unapproved programs within network
- NCDB Data Transmission including History and Edits of Data Submitted to the NCDB as individual programs only
  - unapproved programs within the network are to submit the most current year from the Last Annual Call for Data to the NCDB before survey
- Survey Application Record (SAR) - complete for scheduled survey
CoC Datalink applications that become accessible following survey and network approval include the above plus:
- Facility Information Profile System (FIPS)
- NCDB statistics (reports only for individual programs until network data submission has been made).

Resources for Cancer Programs