How Are Cancer Program Accredited?
Cancer program surveys are a comprehensive evaluation of the entire scope, organization, and activity of a cancer program. A survey is performed every three years by a physician surveyor who is specially trained to evaluate compliance with the 36 standards that are required for accreditation.
Program standards are outlined in the manual CoC Cancer Program Standards 2009, Revised Edition. Standards for data collection are presented in Facility Oncology Registry Data Standards (FORDS).
Each program being surveyed must complete the Web-enabled Survey Application Record (SAR). The SAR provides background on the structure of the program and activity since the last survey. It also includes the evaluation standards and allows the program and surveyor to rate compliance with each standard.
An independent review of a program's application and supporting documentation is performed by a Cancer Program Specialist team member in the Accreditation and Standards section of Cancer Programs. Program-related activity and standard ratings may also be reviewed by the multi-disciplinary Program Review Subcommittee before an accreditation award is assigned.
Accreditation Awards
Accreditation awards are based on compliance with the 36 standards. Programs with a deficiency in any standard are allowed 12 months to document changes for administrative review in order to receive full accreditation.
The accreditation awards are as follows:
| Three-Year with Commendation |
Three-Year Accreditation |
Three-Year with Contingency | Non accreditation |
Accreditation Deferred (Valid only for New Programs) |
|
| 36 Standards | No deficiencies and one or more commendation(s) |
No deficiencies, but without commendation |
1 - 7 deficiencies | 8 or more deficiencies |
1 deficiency |
Three-Year with Commendation is given to programs, either new or established, that comply with all standards and receive a commendation rating for one or more standard. A certificate of accreditation is issued and these programs are surveyed at a three-year interval from the date of the survey.
Three-Year Accreditation is given to programs, either new or established, that comply with all standards but do not receive a commendation rating for any standards. A certificate of accreditation is issued and these programs are surveyed at a three-year interval from the date of the survey.
Three-Year Accreditation with Contingency is given when 1 to 7 standards are rated deficient. The contingency status is resolved by the submission of documentation of compliance within 12 months. Documentation required to resolve the deficiency for each standard is available on the Cancer Programs page of the American College of Surgeons Web site. Three-Year with Commendation or Three-Year Accreditation is granted following submission of documentation. A certificate of accreditation is issued after resolution of deficiencies and these programs are surveyed at a three-year interval from the date of the survey.
Nonaccreditation is given when 8 or more standards are rated deficient. Programs are encouraged to improve their performance and may reapply.
Accreditation Deferred is given when a new program is rated deficient in 1 standard. The deferred status is resolved by the submission of documentation of compliance within 12 months. Documentation required to resolve the deficiency for each standard is available on the Cancer Programs page of the American College of Surgeons Web site. Three-Year with Commendation or Three-Year Accreditation is granted following submission of documentation without resurvey. A certificate of accreditation is issued after resolution of deficiencies and these programs are surveyed at a three-year interval from the date of the submission of documentation. Programs that do not resolve this status at the end of the 12-month period must reapply for survey.
Revised April 21, 2009