If your facility plans to form a network with at least one hospital and one or more other facilities, the Commission on Cancer (CoC) requests that you first review the Guidelines for Network Cancer Programs presented below. After reviewing the guidelines, please complete the Network Notification Form (65K DOC) and submit it to Karen Stachon via e-mail at kstachon@facs.org. Questions regarding the Guidelines for Network Cancer Programs should also be directed to Karen Stachon at the email address provided.

The following topics are addressed within these guidelines:

• Network Checklist
  Network Notification Form (65K DOC)
• Demographic Information
• Definition and Eligibility Criteria
• Cancer Program Identification
• Network Processing
  • Cancer Liaison Physician (CLP)
  • 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)

Network Checklist

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

• Download, complete, and submit the Network Notification Form (65K DOC)
• Identify network Cancer Liaison Physician(s) and indicate on the Network Notification Form.
• Coordinate cancer registry data in preparation for network registry operations and CoC standard compliance.
• Determine reference date for network program. If changing reference year for individual accredited programs to match the network reference year, complete the Reference Date Change Request Form.
• Fax or e-mail a network request letter, drafted by the network cancer committee chair or administrator, requesting the category change to a Network Cancer Program along with the completed Network Notification Form to Karen Stachon.
• Receive e-mail confirmation from the CoC with the new facility identification number (FIN) and category.
• Share a copy of the completed Network Notification Form and CoC confirmation with appropriate cancer program staff at the facility.
• Determine network consult date with a CoC-trained network consultant and receive access to the Consult Survey Application Record (C-SAR), which will be provided to the network cancer registrar.
• Work with the network cancer committee to complete the C-SAR in preparation for consult.
• When the network program is scheduled for initial survey, CoC Datalinks access will become available to perform the following actions under the new FIN:
  • Review and sign HIPAA Business Associate Agreement (BAA) for network and unaccredited programs within network.
  • Update facility and staff contact information for the network.
  • Review NCDB data transmission, including history and edits of data submitted to the NCDB as individual programs.
    • Non-accredited programs within the network are to submit the most current data from the last Annual Call for Data to the NCDB prior to the survey.
  • Complete the SAR for the scheduled survey.
• CoC Datalinks applications that become accessible only following survey and network accreditation include the following:
  • FIPS
  • NCDB statistics

Demographic Information

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

1. Complete name, street address, city, state, zip code, phone number, and Web site address (URL) of the network program.
2. Complete name, street address, city, state, zip code, and 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:

• network CEO/president/administrator
• network cancer program director/administrator
• cancer committee chair
• cancer liaison physician
• network cancer registrar
  (The selection of these contacts is left to the discretion of the network program.)

Definition and Eligibility Criteria

• A network cancer program consists of individually operated facilities (at least two) that are all owned by the same entity or corporation. One must be a hospital. 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
  • American Osteopathic Association (AOA)
  • A health facility licensure organization (usually located within a state health department)
• Networks are characterized by the following:
  • a network-wide cancer committee or other appropriate leadership body
  • standardized cancer registry operations with a uniform data repository
  • coordinated service locations and practitioners within the network
  • participation in clinical research (required)
• The difference between a CoC "network cancer program" and a CoC "merged cancer program":
  • Network: Each facility is individually operated and accredited but all are owned by the same parent company.
  • Merged: One hospital now owns another hospital. The merged hospital may have multiple campuses that are operated and accredited as one facility under one FIN.

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 Cancer Program Standards 2009, Revised Edition manual for additional requirements for network programs.

Cancer Program Identification

Following receipt of the Network Notification Form, CoC Cancer Program staff will provide the network cancer committee chair, cancer liaison physician, cancer program administrator, and cancer registrar with an e-mail confirming the network category along with a new FIN for the program. Until the network has a formal survey and receives full accreditation, the currently CoC-accredited individual facilities will maintain their current CoC FINs, accreditation status, and cancer program category.

Network Processing

Cancer Liaison Physician

A single cancer liaison physician (CLP) should be appointed to serve the network. In most cases, a CLP 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.

New networks may optionally 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 network believes that it is necessary to appoint more than one CLP (most likely if facilities are separated geographically), please contact Carolyn Jones at cjones@facs.org. The network must submit its rationale in writing in order to receive permission to maintain more than one CLP.

Reference Date

It is recommended that an existing reference date from one of the CoC-accredited 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 CoC-accredited 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 other appropriate leadership body and must be submitted to Lisa Landvogt by fax at 312-202-5009 or e-mail at llandvogt@facs.org using the Request to Change Reference Year Form.

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

• current CoC guidelines on reference dates
• current status (CoC accredited) of the individual facilities
• the earliest reference date of the accredited individual facilities within the network

Confirmation of the reference date change for the individual CoC-accredited programs will be provided to the cancer registrar via e-mail.

Network Consultation

The standards described in the Cancer Program Standards 2009, 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 a CoC-trained network consultant to coordinate the network consult. Once a date for consultation has been established and the CoC is notified, the network cancer registrar and consultant will be provided access to the C-SAR for consult preparation. The C-SAR is located in the password protected section of CoC Datalinks. When the program has been released for survey by the consultant, the information will be copied over to the SAR for survey preparation. The fee for the consultation is negotiated with the CoC-trained network consultant who is chosen to perform the consult. The consult visit will cover the following areas:

• meeting with the network cancer program team
• review of C-SAR
• review of documentation to support compliance with the network standards
• review of abstracts from each facility
• review of pathology reports from each facility
• attendance at a cancer conference
• tour of 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 2009, Revised Edition to receive full accreditation.

Cancer Registry Operations and Database Management

The network is required to coordinate the existing data sets from each individual facility and maintain follow-up activities for all cases within 12 months of the formal network formation. When 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 for the new combined registry so that the primary source of the information is retained. 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.

• If the registry data for the network are to be merged into a combined registry, with newly assigned accession numbers, please contact Jerri Linn Phillips at jphillips@facs.org to arrange to resubmit all merged data from 1985 diagnoses forward using the new identification numbers. NCDB will need to remove the previously-submitted data for all affected programs from its database prior to this resubmission. The combined registry should have the assigned FIN for the network program stored in the FIN (NAACCR #450) area.
• As long as the individual facilities retain their original separately-numbered accession numbers, in separate registries or a coordinated one, it is essential to continue to use the legacy (historic) FINs rather than the network FIN for both the FIN and Archive FIN data items for all cases. Do not use the network FIN when the campuses maintain separate accession numbering. NCDB will identify the legacy FINs as belonging to the network FIN and will handle the cases appropriately.

Program access to CoC Datalinks and the NCDB data submission history or SAR standards 3.6, 3.7, or 3.8 histories for the individual facilities and for the network will be accommodated through the new network FIN once the network has been accredited. Prior to accreditation of the network, access will be available only through the legacy FINs.

Previously CoC-accredited programs are required to submit NCDB data from the time of the network 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 network accreditation forward, but earlier cases may be submitted at the program’s discretion.

All the information for submitting data can be found on the NCDB Web page at http://www.facs.org/cancer/ncdb/datasubmission.html. Facility staff should contact Anna Delev via email at adelev@facs.org if clarification of submission guidelines is necessary.

Preparing for Initial Survey

Once the network consultation has taken place and the program has been released for the initial
network survey, the following applications become available, with some requiring attention and
action:

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 network, 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:

• HIPAA Business Associate Agreement
• facility and staff contact information
• FIPS
• NCDB
• SAR

Until the network has a formal survey and receives full CoC accreditation, the individual facilities currently accredited 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 accreditation, the CoC Datalinks applications for the individual facilities will no longer be accessible. The network is responsible for signing the HIPAA BAA, submitting new facility and staff contact information, and completing a new SAR under the newly-assigned network FIN.

The designated network 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 formation of the network, their user IDs and passwords will remain the same and can be used to access the network facility's CoC Datalinks applications. Those who were not identified as designated staff by the network facility will no longer be authorized users.

If the network facility assigns a new network cancer registrar, cancer committee chair, cancer liaison physician, 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 must never be shared. The CoC is not responsible for the unauthorized release or sharing of log-in information and data by any CoC Datalinks user.

Once accredited, a network may request CoC Datalinks access for additional members of the cancer program and/or medical staff. These additional users must complete the Request for an Additional User Form (50K PDF). It is at the discretion of the network to designate the additional users and to notify the CoC of these users.

Facility and Staff Contact Information

After the CoC releases the network for survey, the cancer registrar or designee must access the facility and staff contact information section within CoC Datalinks to 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” to assist you with accreditation and quality improvement efforts of your cancer program. To accomplish these tasks, the ACoS must enter into Business Associate Agreements (BAA) 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 network program can access the BAA to submit an 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 http://www.facs.org/cancer/coc/hipaa.html.

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 program

A BAA has been individually signed by each CoC-accredited facility involved in the network. Facilities that are part of the network but not currently accredited by the CoC are not business associates of the ACoS and have not signed a BAA. Once the program receives confirmation that the network has been released for survey by the CoC, the network program must immediately access CoC Datalinks to sign the BAA. The network will not be officially recognized by the CoC until this initial step is complete. The BAA currently in effect prior to the recognition of the network will remain in effect until a BAA for the network facility is signed.

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

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-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 the public on the ACS 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 accredited by the CoC are listed separately in FIPS. Following network accreditation, a new 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 and the information for individual facilities will no longer be shared with the ACS.

Following network accreditation, 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 to authorize release of the cancer caseload data to the ACS within 90 days of becoming a network.

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

NCDB Statistical Tools

New networks will have access to the Survival Reports for the merged program once the network has been accredited. However, the Hospital Comparison Benchmark Reports, Electronic Quality Improvement Packets (e-QuIP), and Cancer Program Practice Profile Reports (CP³R) are updated annually and will become available to the new network 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 network accreditation. 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 are required 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 designated cancer program staff are notified by e-mail when the SAR is available for survey preparation, ongoing tracking of program activity, or Annual Update completion.
• For programs due for a survey, the SAR is available until three business days following the date of the survey.
• The tracking activity SAR is available to all CoC-accredited programs throughout the three year survey cycle. For programs that have recently been surveyed, the tracking activity SAR is opened when the survey results are available and the Accredited Cancer Program Performance Report is posted in CoC Datalinks.
• On an annual basis, programs are required to update certain sections of the application for the SAR. This information is used to analyze overall program activity in specific areas.

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.

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

Once the network receives full accreditation, the individual facilities’ FINs, accreditation status, and cancer program category will be made inactive in the CoC Cancer Program Database, but 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 accreditation is achieved. All facilities within the network will receive a certificate of accreditation 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.

Revised July 20, 2009

Resources for Cancer Programs